Fillable Purchasing Vendor Profile Questionnaire/Diversity Classification Form services this (Roosevelt University)

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Purchasing Vendor Profile Questionnaire/Diversity Classification Form services this (Roosevelt University)

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  • 21 check-boxes
  • 18 other fields

Country of origin: US
File type: PDF

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430 South Michigan Ave Chicago, IL 60605-1394
Please Fax or E-mail to (312) 341-3594/purchasing@roosevelt.edu
Purchasing Vendor Profile Questionnaire/Diversity Classification Form
Company Information
Company,QGLYLGXDO Name:
Address:
Phone Number:
Fax:
Contact Name:
Email:
Please list products or
services this company
provides:
Legal Structure (Check one)
Sole Proprietor
Partnership
Corporation
Non-Profit/Association
Diversity Classifications (Check all that Apply)
Is the owner(s) of this business a US citizen(s)?
Yes
No
Is this business certified as a Minority Business Enterprise (MBE)?
Yes
No
African American
Hispanic-A
merican
Native-American
Asian Pacific-American
Asian-American
Other (please specify:
This business is at least 51% owned and controlled by one or more minority persons.
This is a certified Women Business Enterprise (WBE).
This is a Women Business Enterprise is at least 51% owned and controlled by one or more women.
This is a Disadvantaged Business Enterprise (DBE).
This is a Veteran-owned Small Business (VOSB) or Service-Disabled Veteran Small Business.
This is a Business a certified Small Business as defined by SBA.
If you have checked any of the above, by what Agency have you been certified?
Such as, but not limited to:
State of Illinois Central Management Services
City of Chicago
Cook County and Minority Business Development
Small Business Association (SBA)
Roosevelt University’s Conflict Of Interest provision, the Vendor certifies the following:
There are no identified conflicts of interest (such as being a University employee, trustee or family member)
The following potential conflict of interest has been identified:
Name of University Employee:
Relationship to Business:
% Business Owned By:
Signature:
Date:
The University reserves the right to reject a vendor’s information application when a clear conflict of interest is evident. University policy
dictates fair competition and Roosevelt University embraces applicable guidelines as detailed in the bylaws of the National Association of
Educational Procurement. Thank you for your interest in becoming a vendor.
*Not For Services*
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Purchasing Vendor Profile QuestionnaireDiversity Classification Form services this (Roosevelt University)

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Completed 21 July 2020

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