Bennett International Group, LLC

Diverse supplier application form

Please note that completion of this form is the first of three-steps in Bennett International Group's Diverse Supplier Registration Process. All applications must be submitted electronically through Bennett International Group's Web site. A return e-mail address is required for all applications. Thank you again for your interest in Bennett International Group's Supplier Diversity Initiative.

Supplier registration

Please complete the following information to register with Bennett International Group as a minority- or woman-owned business. This information will be reviewed by the appropriate buyers for potential opportunities.

Fields with an * are required.

Company information

*Company name:
*Address:
*City:
*State:
*Zip code:
*Contact name:
*Phone:
Fax:
*E-mail:
Internet address:


*Type of product(s) or service(s) offered:


* Company type:

* Year business established:


Annual sales: (past 3 years)
*Year 1:  Most recent complete fiscal year
*Year 2:  
*Year 3:


*Geographical service area: please check all that apply
West coast (CA, OR, WA, ID, NV, AZ, UT)
South central (CO, TX, OK, LA, MS, MO, NM, AR)
North central (IL, IN, MI, OH, WI, IA, KS, NE, WY, SD, ND, MT, MN)
Southeast (AL, FL, GA, KY, MI, NC, SC, TN)
Northeast (DE, MD, PA, VA, WV, NY, NJ, CT, ME, MA, NH, RI, VT, DC)
International

*Standard industrial classification system (NAICS) code (click here to search for your code):
1.
2.
3.
4.
5.
6.

Dunn#:

*Federal tax ID#:

*# of employees:

*# of minority employees:

Company classification

*Are you 51% owned/operated by one of the following diverse groups:
(Contact the nearest U.S. Small Business Admin. office (S.B.A.) for guidance if you have questions)

  

Please check all that apply:

Minority-owned business enterprise1
African American
Asian Indian American
Asian Pacific American		 Hispanic American
Native American
Multi-Cultural, Other

Women-owned business enterprise2
Small disadvantaged business (SDB)
Disabled owned
HUBZone
8(A) designation
Disadvantaged veteran enterprise (DVE)
Disabled veteran business enterprise (DVBE)
Service disabled veteran (SDV)
Veteran business enterprise (VBE)
Vietnam veteran
Historically black colleges and universities and minority institutions
N/A

Principal owner(s) - please fill in at least one principal owner.
*Name: *Title: *% Ownership:
1
2
3
 
 

*Has your business been certified as minority or women owned by any government agency or private agency?  
Yes No

 

If yes, then please select the name of the certifying organization:

If you selected "other" please fill in the name of the certifying organization:

*I certify to Bennett International Group that the information provided is true and correct and that I will advise Bennett if our classification should change:

* Name:

* Title:

* Phone:


Yes No

 

1) MINORITY BUSINESS ENTERPRISE, means a business that (1) is at least 51 percent owned by one or more minority individuals, or a publicly owned business having at least 51 percent of its stock owned by one or more minority individuals, and (2) that minority person or persons is actively involved in the day-to-day management and operation, AND is involved in policy decision-making.

2) WOMEN-OWNED BUSINESS ENTERPRISE, means a business that (1) is at least 51 percent owned by a woman or women or a publicly owned business having at least 51 percent of its stock owned by one or more women, and (2) that woman or women is actively involved in the day-to-day management and operation, AND is involved in policy decision-making.