Supplier Diversity Program—Supplier Profile 2010
PART 1: GENERAL INFORMATION
Company Name
/Dun & Bradstreet ID
/Tax ID
Address
City
/State
/Zip Code
-
Telephone Number
/Fax Number
() - ext:
/() -
Email Address
/Company Website
Owner
/President
Type of Business
Corporation
/Partnership
/Individual
/Other
/(describe)
Years in Business?
/Annual Sales ($)
/SIC/NAICS Codes
List the products and services you supply (PLEASE SEE ATTACHED LIST FOR SUGGESTIONS)
Name of Union and Local #, if any
Number of Permanent Employees
/Number of Temporary Employees (Average)
Geographic area in which you work
Maximum Size of Jobs Handled ($)
/Minimum Size of Jobs Handled ($)
/Ideal Size of Jobs Handled ($)
List of Major Equipment Owned
PART 2: DIVERSITY STATUS AND CERTIFICATION
Are you a Diverse Supplier*?
/Yes
/No
*please see Definitions attached after the Statement of Diversity Status Form
Please complete and return two (2) copies of the attached Statement of Diversity Status form and any supporting Third Party Certification Documentation
Supplier Diversity Program—Supplier Profile (2)
Company Name
/Dun & Bradstreet ID
/Tax ID
PART 3: FINANCIAL REFERENCES
Bank Name
Bank Address
/City
/State
/Zip Code
-
Account Officer
/Telephone Number
() - ext:
Bank Name
Bank Address
/City
/State
/Zip Code
-
Account Officer
/Telephone Number
() - ext:
PART 4: WORK EXPERIENCE
Company Name
/Telephone Number
() - ext:
Contact Name and Title
Address
/City
/State
/Zip Code
-
Product/Services Performed
Size of Contract ($)
/Year(s)
Company Name
/Telephone Number
() - ext:
Contact Name and Title
Address
/City
/State
/Zip Code
-
Product/Services Performed
Size of Contract ($)
/Year(s)
IMPORTANT NOTE:
PLEASE ENCLOSE TWO (2) COPIES OF THE ATTACHED STATEMENT OF DIVERSITY STATUS, ANY SUPPORTING DIVERSE CERTIFICATION, COPIES OF YOUR BROCHURES AND BUSINESS CARDS.WE ACCEPT SUBMISSIONS BOTH AS MAIL OR EMAIL (SEE INFORMATION BELOW), BUT PLEASE KEEP IN MIND ALL DOCUMENTS WILL BE SCANNED INTO AN ELECRONIC DATABASE. OFF SIZE DOCUMENTS ARE DIFFICULT TO SCAN. WE PREFER RECEIVING SUBMISSIONS VIA EMAIL. THANK YOU!
Please return to: Citi Supplier Diversity, ,
or mail to: 111 Wall Street, 18th Floor, New York, NY10005
2010 Statement of Diversity Status
PART 1: GENERAL INFORMATION
Company Name:Dun & Bradstreet ID:
Mailing Address
City: / State: / Zip: / -
Contact Person: / Title:
Phone: / () - ext: / Email:
Fax: / () - / Web Site: /
Type of Firm: / Corporation / Partnership / Individual / Other:
Type of Business: / (please see attached list for suggestions)
Year Business Established: / SIC/NAICS Code(s):
PART 2: DIVERSITY STATUS
Are you a Diverse Supplier*? / YES / NOIf you answered yes to the previous question please answer ALL of the following questions:
Are you a Minority Business Enterprise? / YES / NO
Please check all that apply:
African American / Asian Indian American / Asian Pacific American
Hispanic American / Native American
Are you a Woman Business Enterprise? / YES / NO
Are you a Disabled Business Enterprise? / YES / NO
Are you a Veteran-Owned Business Enterprise?
(please indicate if you are a Service Disabled Vet) / YES SDV / NO
Are you a Small Business Enterprise? / YES / NO
*Please see attached document for guidelines in determining your diverse-owned status
PART 3: THIRD PARTY CERTIFICATION
Has your Diverse Supplier status been certified by a federal, state, municipal government, or any of the local councils (WBENC, NMSDC, etc)? / YES / NO
Certifying Agency:
Date Certified: / Expiration Date:
PLEASE ATTACH A COPY OF YOUR CERTIFICATION DOCUMENTATION
PART 4: SIGNATURE
ON BEHALF OF THE SUPPLIER IDENTIFIED HEREIN, THE UNDERSIGNED CERTIFIES THE STATEMENTS AND ALL ANSWERS TO QUESTIONS LISTED ABOVE AS TRUE AND CORRECT.
Name of Authorized Representative: / Title:
Signature: / Date:
Defining a Citi Diverse Supplier
A Diverse Supplier is a Citi supplier that can be categorized as one of the following:
Minority Business Enterprise (MBE)
A for profit enterprise presently located in the United States or its trust territories, and is at least 51% owned by African Americans, Hispanic Americans, Native Americans, Asian Indian Americans and Asian Pacific Americans. Individual(s) must be involved in the day-to-day management of the business.
- African Americans are U.S. citizens whose origins are in any Black racial groups of Africa.
- Hispanic Americans are U.S. citizens whose origins are in South America, Central America, Mexico, Cuba, the Dominican Republic, Puerto Rico, or the Iberian Peninsula, including Portugal.
- Native Americans are American Indians, Eskimos, Aleuts, and Native Hawaiians.
- Asian Pacific Americans are U.S. citizens whose origins are in Japan, China, the Philippines, Vietnam, Korea, Samoa, Guam, the U.S. Trust Territory of the Pacific Islands (Republic of Palau), the Northern Mariana Islands, Laos, Kampuchea (Cambodia), Taiwan, Burma, Thailand, Malaysia, Indonesia, Singapore, Brunei, Republic of the Marshall Islands, or the Federated States of Micronesia.
- Asian Indian Americans are U.S. citizens whose origins are in India, Pakistan, Bangladesh, Sri Lanka, Bhutan, or Nepal.
Woman Business Enterprise (WBE)
A for profit enterprise presently located in the United States or its trust territories, and is at least 51% owned, controlled, and operated by a woman or women of US citizenship. Individual(s) must be involved in the day-to-day management of the business.
Disabled Business Enterprise (DBE)
A for profit enterprise presently located in the United States or its trust territories, and is at least 51% owned by an individual(s) of US citizenship with a permanent physical or mental impairment which substantially limits one or more of such persons’ major life activities. Individual(s) must be involved in the day-to-day management of the business.
Veteran-Owned Business Enterprise/Service Disabled Veteran-Owned Enterprise (VET/SDV)
A for profit enterprise presently located in the United States or its trust territories, and is at least 51% owned by an individual(s) who have performed active service in one of the United States armed services, and were honorably discharged. The term “service-disabled” means that such disability was incurred or aggravated in line of duty in the active military, naval or air-service. Individual(s) must be involved in the day-to-day management of the business.
Small Business Enterprise (SBE)
A small business (as defined pursuant to Section 3 of the Small Business Act) presently located in the United States or its trust territories. The Small Business Act states that a small business concern is "one that is independently owned and operated and which is not dominant in its field of operation." The law also states that in determining what constitutes a small business, the definition will vary from industry to industry to reflect industry differences accurately.
TYPE OF BUSINESS
- Information Services
- Market Data
- Credit and Data Services
- Hardware
- Desktop
- Distributed
- Mainframe/Midrange
- Storage Devices
- Infrastructure
- Software
- Infrastructure Software
- Enterprise Application Software
- Telecommunications Services
- Wireless
- Network Services
- Telecom Hardware/Multimedia
- Telecommunications Hardware
- MultiMedia Services
- Workforce Services
- Temporary Agencies
- IT Application, Development, and Maintenance
- Consulting
- Legal Services
- Benefits
- HR Staff Services
- Training
- Non-Employee Insurance
- Business Operations & Services
- Print Production
- Cards/Plastics
- Production Equipment
- Marketing and Advertising
- Banking Services and Operations
- Business Process Outsourcing
- Office Products & Services
- Travel
- Logistics
- Office Services
- Office Supplies
- Office Equipment
- Facilities
- Construction & Building Improvement
- Furniture and Fixtures
- Building Services
- Real Estate Leases
- Utilities
- Security (Physical)
- Trade Related Commissions
- Brokerage
- Exchange
- Clearance
Please return to: Citi Supplier Diversity, ,
or mail to: 111 Wall Street, 18th Floor, New York, NY10005