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Supplier Diversity Information Form


Company Name:



Company Description:



Company Address:



Company Phone Number:



Company Fax Number:



Company Contact Name:



Company Contact E-mail Address:



Company Website Address:



Number of Years in Business:



Number of Full-Time Company Employees:



Business Type:

Sole Proprietor
Partnership
Corporation
Other  


DUNS ID:




Please provide three prior years financial information:


Year:


Company Revenue:



Year:


Company Revenue:



Year:


Company Revenue:




Please provide three prior years safety information:


Year:


Company EMR:



Year:


Company EMR:



Year:


Company EMR:




Has the company been involved in any bankruptcy or reorganization proceedings?

Yes
No


Has the company or any officers/principals of the company been the subject of any investigation by the SEC or other governmental agencies?

Yes
No


Has the company been a party to any significant judgments, claims, or lawsuits pending or outstanding?

Yes
No


If answered yes to any questions above, please explain below:



Is the Company E.ON U.S. Certified?

Yes
No


Does the Company have a QA/QC Plan?

Yes
No


Does the Company have a Strategic Plan/Business Plan?

Yes
No


Does the Company have a Legacy Plan/Succession Plan?

Yes
No


Business Classification (check all the applicable categories)

Small Business Enterprise (500 employees or less)
Minority Business Enterprise (Must provide proof of certification)
Woman Business Enterprise (Must provide proof of certification)
Small Disadvantaged Business (SDB)
Disadvantaged Business Enterprise (DBE)
Veteran Owned
Service Disabled Veteran Owned
HUB Zone as defined by Federal Acquisition Regulations (FAR)
8(a) Certified
Union
If Union, please enter affiliated organizations:


Company Certifications and/or Qualifications:


Additional Certifications and/or Qualifications:

1


2

Is the Company EDI Capable?

Yes
No


Does the Company accept Mastercard?

Yes
No


Has the company previously done business with E.ON U.S.?

Yes
No


If answered yes, please provide E.ON U.S. contact name and description of the project:



Please list the Company's last three projects.


Project #1

Client:
Location:
Type of Work:
Client Contact:
Client Telephone:
Project Value:


Project #2

Client:
Location:
Type of Work:
Client Contact:
Client Telephone:
Project Value:


Project #3

Client:
Location:
Type of Work:
Client Contact:
Client Telephone:
Project Value:


NAICS Code (6 char. max):




Desired Project Size:

Minimum:   
Maximum:  

Preparer's Name:


Preparer's Title:


Preparer's Phone Number:


Date:



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