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Supplier Diversity Profile
*Company Name:
Address:
City:
State:
Zip:
*Telephone:
Fax:
Web Site:
E-mail Address:
*Primary Contact First Name:
*Primary Contact Last Name:
Controlling Ownership
Interest:

U.S. Citizen:
Percentage of Ownership:
(by classification)
Type of Ownership:
Date of Incorporation:
State of Incorporation:
Years in Business Under
Current Ownership:
*Date Business Established:
Federal Tax I.D. No. or SSN:
Type of Business: (List Products and/or Services offered)
Number of Employees:
Full Time Part Time Contract
Gross Revenue for previous three years:
Year:
Gross Revenue $
Year:
Gross Revenue $
Year:
Gross Revenue $
Location of Company Facilities:
Address:
City:
State:
Zip:
Is your Company currently certified as M/WBE?:
If Yes, Certification is with:
Please provide three Client References:
Name:
Phone:
Address:
City:
State:
Zip:
Type of Contract:

Name:
Phone:
Address:
City:
State:
Zip:
Type of Contract:

Name:
Phone:
Address:
City:
State:
Zip:
Type of Contract:
Has your business provided products and/or services to BPU?
If Yes, please provide product and/or service provided and name of BPU Contact person:
Products/Services:
Contact Person:
We strongly encourage you to provide the information requested. The more we know about your qualifications, your business and your experience, the better we will be able to match your expertise with opportunities.
By clicking the button below, I declare that I have completed this application and all of the information submitted is true, correct and complete to the best of my knowledge and belief.

I am an owner of for which this application is made.
 
 
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