Minority Vendor Application

DIVISION OF COMMERCE

*Select vendor Type: Individual

	Corporation, Partnership or other Non Individual Entitiy
	State or Location of Creation:
	Date of Creation:

Company submitting application must be at least fifty-one percent (51%) owned ,
operated and controlled by one or more minority individuals with US citizenship.

*Minority Category:

Minority Vendor Information
*Vendor Legal Name:
Parent Company:

Physical Address
*Address Line 1:
Address Line 2:
*City:
*State:
*Zip:

Mailing Address: (if different)
Address Line 1:
Address Line 2:
City:
State:
Zip:

*Phone:
Fax:
Website:
Email:


Employer's / Federal ID Number:
SSN ( for Indv Only):
Number of Full Time Employees:
Number of Part Time Employees:
Number of Minority Employees:
*Is your company bonded?:	No Yes
If yes, Amount $:
If yes, Bonding/Security Co:

Please give a concise description of your company products, services, or type of construction. If your
company offers more than one product or service, list primary products or service first.

*Description:

If you are a certified NAICS code holder, please supply approved code numbers:

Primary:
Secondary:

*Owners/Stakeholder

First Name	Last Name	Title

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