MBE / WBE Vendor Inquiry / Contact Application

Company Information
Company Name:

Doing Business As:

Corporate Address:

Address Line 2:

Address Line 3:

City:

State/Region:

Zip/Postal Code:

Country:

Contact Name:

Position / Title:

Contact Phone Number:

Contact Email Address:



Company Data
Business Type:

If Other, enter description

Legal Structure:

State of Incorporation:

Geographical Service Area:
Does your company use a SSN or TIN?

SSN or Fed Tax ID #:

(SSN if Sole Proprietorship, if multiple Tax ID's Exist, use Purchase From Company/Branch Tax ID Number.)

Is your company publicly traded?

If yes, please provide your stock ticker ID:


License And Permit Information
Please provide information on each type of Vendor's business license(s) to conduct business. This request should include any specialized license(s) for your industry, and any other licenses or certificates, required to operate your business.

Type of License License Number Exp. Date

Has your Vendor or any of its affiliated companies, any owner, director, officer of the vendor, or any predecessor to any of the foregoing, ever had any license or certificate issued by any jurisdiction denied, restricted, suspended, revoked or not renewed?
 


Select the following Isle of Capri company(s) you are interesting in doing business with.

Business Category Type
Please select all categories that apply.





Certification
Is your business currently certified as an MBE / MWBE / WBE with a National - Regional or Federal / State or City Organization or Agency?

 
If your company is certified please list the certifying Agency and upload a copy of your certification below.

Certifying Type (1):

Certifying Agency:

Certifying Number:

Expiration Date:

Upload Certificate:


Certifying Type (2):

Certifying Agency:

Certifying Number:

Expiration Date:

Upload Certificate:


Products And/Or Services
Please provide a description of your products and services.

 
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