Please fill out the for below Vendor Registration Form
(* Required Field) |
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Vendor Name: * |
Vendor Name is Required. |
DBA Name: |
DBA Name is Required. |
Contact Name: * |
Contact Name is Required. |
Title: * |
Title is Required. |
Email Address: * |
Email Address Required. |
Street Address: * |
Street Address Required. |
City* |
City is Required. |
State* |
Please select an item. |
Zip Code* |
Zip Code is Required. |
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Is the mailing address same as physical address?*
Yes
No
Please make a selection. |
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Mailing Address
(If Different from Street Address): |
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City |
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State |
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Zip Code |
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Telephone: |
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Fax: |
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Website:: |
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Business Structure (mark only one ):* |
Sole Proprietorship
Nonprofit Organization
Partnership
Incorporated Business
Other
Please make a selection.
(if other please list)
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Are you currently doing or have you ever done business with EMCO before?* |
Yes
No
Please make a selection. |
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Please describe your business, areas of expertise, and products: * |
Description required. |
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NAICS Code ( please list no more than three in order of your expertise): to find a list of available NAICS codes, visit www.census.gov/eos/www/naics
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* 1. |
NAICS Required. |
* 2. |
NAICS Required. |
* 3. |
NAICS Required. |
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Federal Tax ID Number: * |
Federal Tax ID Required. |
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Vendor Classification (check all that apply): *
Minority Business Enterprise (MBE)
Disadvantaged Business Enterprise (DBE)
8(a)
Women's Business Enterprise (WBE)
Hub Zone
Please make a selection. |
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Minority certification provided by (check all that apply ): *
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National Minority Supplier Development Council (NMSDC)
Women's Business Enterprise National Council (WBENC)
Other
Please make a selection. |
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Please provide copy of certificate with this completed form - the certificate is required
(doc, docx, Pdfs files only)
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Under penalties of perjury, I certify that:*
Name Required. (full name) swear or affirm under penalty of law that I am*
Title Required. (title) of applicant firm*
A applicant firm is Required. (firm name) and that I have read this registration form and that all of the statements submitted in this form and its attachments are true and correct to the best of my knowledge. The responses include pertinent history information about the name, as well as the ownership and affiliations of the firm.
Vendor Agrees *
Please verify everything above is correctPlease type your name
Enter Date*
Enter Date |
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| Please send this application plus a copy of your NMSDC or WBENC certifications to diversity@emcobr.com or mail to Diversity, 8900 South Choctaw Drive, Baton Rouge, LA 70815. |
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