Supplier Information Form

Contact Information

* Company Name:
* Contact First Name:
* Contact Last Name:
* Contact Title:
* Contact Phone:
* Contact Fax:
* Contact Email:
* Contact Address 1:
Contact Address 2:
* City:
* State:
* Zip Code:

Is contact a company principal?

Company Information

Diversity Classification: Select all that apply.

Minority Business Enterprise
 Specifiy Minority: 
Women Business Enterprise
Veteran-owned Business Enterprise

Does your company have a certified diversity designation?  If yes, upon completion of this form, you will be asked to email a PDF copy of  your certification(s). If no, you can apply for certification from the following organizations:

Minority Business Enterprise:
www.scomb.orgOff Site Icon
www.odod.ohio.govOff Site Icon
www.cityofdayton.orgOff Site Icon

Veteran Owned Business Enterprise:
www.sba.govOff Site Icon Site Icon

Women Business Enterprise:
www.wbenc.orgOff Site Icon
www.nwboc.orgOff Site Icon
www.womenbiz.govOff Site Icon
www.orvwbc.orgOff Site Icon

* Number of Employees:
* Annual Company-wide Sales:
(in U.S. dollars)
* Tax ID Number:

D-U-N-S Number:
Request a D-U-N-S number.

* Description of Service(s):
Please limit to 800 characters.
* Type of Ownership:
* Year of Incorporation:
* Company Website

Product Information

* Product Category:
Please limit to 800 characters.
* Product/Service description(s):
Please limit to 500 characters.
* NAICS Commodity Code(s):
* Please provide references, include
organization name and contact
information of current users of the
Please limit to 800 characters.

* Have you done business with a PHP
organization in the past?

If yes, please provide
organization and contact name:

Notes or special concern:  


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