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Supplier Registration Information

Required fields are bold.
 

Section I. Business Section

Company Information
* Legal Company Name:
  DBA Company Name:
* User Name:
* Federal Tax ID:
  D&B DUNS Number:
  Company Website (URL):
 
Physical Address
* Address:
   
* City:
* State
* Zip / Postal Code:
 
Remit to Address is same as Physical Address.
 
Remit to Address
* Address:
   
* City:
* State
* Zip / Postal Code:
 
Purchasing Site Address is same as Physical Address.
 
Purchasing Site
* Address:
   
* City:
* State
* Zip / Postal Code:
 
Payable Site Address is same as Physical Address.
 
Payable Site
* Address:
   
* City:
* State
* Zip / Postal Code:
 
Is your company publicly traded or privately owned?
 
  What is the Ticker Symbol?
  Is the Company governed by the NASD?
 

Principal Owner Information
Owner 1
Name   Title   E-mail
Gender Owner Ethnicity % Ownership
 
Owner 2
Name   Title   E-mail
Gender Owner Ethnicity % Ownership
 
Owner 3
Name   Title   E-mail
Gender Owner Ethnicity % Ownership
 
 

Contact Information
* Contact Name:
  Title:
* Phone Number: Ext.
  Fax Number:
* E-Mail Address:
 

Secondary Contact Information
  Contact Name:
  Title:
  Phone Number: Ext.
  Fax Number:
  E-Mail Address:
 
 

Section II. Business Biography

Company Data
* Legal Structure:
 
Geographical Service Areas:
 
  What State and/or Country are you registered to collect tax?
  Year Business was Established:
* Number of Employees:
 
*
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