Company Name:
Physical Address:
Address:
City: State: Zip:
Remittance Address:
Address:
City: State: Zip:
Please enter your Employee ID Number (EIN) [Federal Tax Identification Number]:
Contact Name:
Contact Title:
Contact Phone: Contact Fax:
Business Email:
Website:
Is your firm certified as a small, women, or minority (SWaM) vendor?
If you answered "No" above, please visit: http://www.dmbe.virginia.gov/index.html to learn more about certification.
Type of Certification, please select all that apply: (hold [Ctrl] key for multiple selections)
Certification Agency, please select all that apply: (hold [Ctrl] key for multiple selections)
If "Other" was selected above, please specify:
Type of Services, please select one:
Business Description (please describe your business):
Please indicate the race/ethnicity of the owner of the company (used for statistical purposes only):
If "Other" was selected above, please specify:
Please indicate the gender of the owner of the company (used for statistical purposes only):
Do you accept credit cards as a form of payment?
Which NIGP commodity codes accurately reflect your business? Please list up to five.
I certify that the information contained herein is true to the best of my knowledge.
Authorized Name:
Date:
Security Measure