VENDOR REGISTRATION FORM

Parent Company Name:

Trading as Name:        

E-Mail Address:           

Telephone #:              

Fax #:                       

Payment Address:

City: State: South Carolina 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 Dakota Tennessee Texas Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code:

Correspondence Address:

City: State: South Carolina 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 Dakota Tennessee Texas Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code:

Federal Employer's ID:

If Dorchester County business, Business License #:

Organization Type:                             

Corporation
Government
Service
Proprietorship
Medical
Non-Profit
Partnership

Product Type:

Merchandise
Service

Specify commodities or services you can provide which:

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COMPANY SIZE/STATUS

A Minority Business is any firm in which minority persons collectively own and share in earnings of 51 per cent (51%) or more of the firm. Minority means Black, Hispanic, Asian, Pacific Islander, American INdian, Alaskan Native, and Women, regardless of race or ethnicity.

Business Type: Check ALL That Apply

If you are a "Minority" firm, indicate the category(ies) below which best denote your minority status. You may select "G", if applicable, and any one of "A" through "F".

NOTE:

FRAUDULENT OR KNOWING, WRONGFUL, OR WILLFUL ACTION TAKEN TO OBTAIN CERTIFICATION AS A MINORITY BUSINESS ENTERPRISE IS PUNISHABLE AS A CLASS I MISDEMEANOR

Submitter Information:

Name:

Title: 

Date: 07/15/2005