Vendor Profile Form

Vendor Profile Form

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: 

 



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