supplier diversity
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Supplier Registration Form
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Supplier Registration Information
Required fields are noted with an asterisk (*).
Please note that if you take longer than thirty minutes to complete this form, it is highly likely that your internet session will be timed out and your registration form will not go through successfully. If you believe it will take you longer than thirty minutes, hitting the Continue button at the bottom will bring you back to the top of the form and allow you a fresh thirty minutes to work with. It is suggested that you gather the required information prior to attempting to complete the form.
Section I. Business Section
Company Information
*
Legal Company Name:
DBA Company Name:
*
User Name:
*
Federal Tax ID / SS#:
D&B DUNS Number:
Company Website (URL):
Physical Address
*
Address:
*
City:
*
State
Select One
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*
Zip / Postal Code:
Remit to Address is same as Physical Address.
Remit to Address
*
Address:
*
City:
*
State
Select One
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*
Zip / Postal Code:
Contact Information
*
Contact Name:
*
Title:
*
Phone Number:
Ext.
*
Fax Number:
*
E-Mail Address:
*
Is your company publicly traded or privately owned?
Publicly Traded
Privately Owned
What is the Ticker Symbol?
Is the Company governed by the NASD?
Yes
No
Principal Owner Information
Owner 1
Name
Title
E-mail
Gender
Owner Ethnicity
% Ownership
Select One
Male
Female
Select One
African American
Asian Indian American
Asian Pacific American
Eskimos/Aleuts
Hispanic American
Native American
Non-Minority
Owner 2
Name
Title
E-mail
Gender
Owner Ethnicity
% Ownership
Select One
Male
Female
Select One
African American
Asian Indian American
Asian Pacific American
Eskimos/Aleuts
Hispanic American
Native American
Non-Minority
Owner 3
Name
Title
E-mail
Gender
Owner Ethnicity
% Ownership
Select One
Male
Female
Select One
African American
Asian Indian American
Asian Pacific American
Eskimos/Aleuts
Hispanic American
Native American
Non-Minority
Section II. Business Biography
Company Data
*
Business Type:
Select One
Broker
Distributor
Manufacturer
Service
*
Geographical Service Areas:
Local (USA)
Regional (USA)
Mideast Region
Pacific Region
National (USA)
Atlantic Region
Please Click Here To Select Countries Serviced
YOU WILL NOT BE ABLE TO TYPE INTO THIS BOX.
To remove items from the list above,
highlight the Regional Service Area and click the
Remove From List
button.
*
Is your company currently working with an Interpublic company?
Yes
No
Company Name
Contact Name
Phone Number
*
Year Business was Established:
*
Number of Employees:
*
Select SIC code(s)
Remove From List
Select SIC code(s)
*
Select Primary NAICS Code
Select Primary NAICS Code
Select Secondary NAICS code(s)
Remove From List
Select Secondary NAICS code(s)
*
Select Commodity Code(s)
Remove From List
Select Commodity Code(s)
Describe the Product Lines / Services your company provides using keywords:
*
Annual Sales For
2007
:
Annual Sales For
2006
:
Annual Sales For
2005
:
References
Please list other customer references that are in the Advertising, Marketing or Communications industry.
Reference 1
Company Name
Contact Name
Phone
Email
Reference 2
Company Name
Contact Name
Phone
Email
Reference 3
Company Name
Contact Name
Phone
Email
Section III. E-Business Readiness
*
Can you sell your products/services online?
*
Are you Electronic Data Interchange (EDI) capable?
Yes
No
Yes
No
*
Do you have an online catalog?
Yes
No
Check
ACH$
US$
Net60