This Form will not be accepted or processed unless it is completed in its entirety. Company Information Corporate/Business Address: Legal Company Name Street/P.O. Box: City: State/Province: Postal Code: Telephone: Fax: Website: Main Administrative Contact Name: Title: Main Administrative Contact Email: Contact Phone: Request For Quote Contact Name: Title: Request For Quote Contact Email: Contact Phone: If Yes, fill in shaded area. If no, continue to next question. Street/P.O. Box: City: State/Province: Postal Code: Would you like to add additional locations (that you want us to know about), that have the same Federal Tax I.D. with which you are pre-qualifying? Yes No If Yes, fill in shaded area. If no, continue to Business Type Location Name: Address: City: State: Postal Code: Contact: Phone: Email: Note: If you have more than one additional location please list on separate sheet and attach. Business Type: Corporation Partnership* Sole Proprietor LLC Venture** *If Partnership is checked General Limited Association **If Joint Venture is checked Please list the Name(s) of all Venture Partner(s): Number of years under present Ownership: Year Business was established: Is your company a Subsidiary? Yes No If Yes, fill in shaded area List Parent Company Name:
Registered / Certified Business: Has your company been classified as a Certified Business in any of categories or from any of these agencies? (Minority, Woman Owned, Veteran, Small Business, Disadvantaged Business, Federal, County, or City) Yes No If yes, please answer the following questions below. If NO, continue on to next page. Is your Company Minority Registered / Certified? Yes No If yes, fill in shaded area. If no, continue to next question. NMSDC (National Minority Supplier Development Council) (Please list state) City (Please List) Other (Please list) Is your Company Registered / Certified as Woman Owned Business? Yes No If yes, fill in shaded area. If no, continue to next question. (Women's Business Enterprise National Council) Which Council? (Please list). City (Please list) Other (Please list) Federal Is your Company a Certified Veteran or Registered Federal Business (excluding Woman-Owned)? Yes No If yes, fill in shaded area below. If No, continue to Next Question. DB (Disadvantaged Business) VOB (Veteran Owned Business) SDVOB (Service Disabled VOB) HZB (HUB Zone) Self Certified Business (SB) 8 (a) CERT (Certified Business) Other (please list) Is your Company State or County Registered / Certified (excluding Women Owned or Minority)? Yes No If yes, fill in shaded area below. If No, continue to Next Question. Which U.S. State does your State / County certification come from? If County, which were you certified in: DBE (Disadvantage Business enterprise) Choose certifying agency below DOT(Department of Transportation) DDOT (Detroit Department of Transportation) WCC (Wayne County Certified) Other please list: Is your Company City Registered / Certified (excluding Women Owned or Minority)? Yes No If yes, fill in shaded area below. If No, continue to Next Question. U.S. State does your city certification come from? City does your certification come from? Please check all that applies below: (City Based Business) (City Headquartered Business) (City Small Business Enterprise) Other (please list) Other Registrations / Certifications If checked, fill in shaded area below. Please list any other Registered or Certified Business Certifications not listed above: Quality: Do you have a Registered Quality Management System? Yes No If yes, fill in shaded area and continue to Design Software. If no, then continue to next question. Agency Name Date Certified