430 South Michigan Ave Chicago, IL 60605-1394
Please Fax or E-mail to (312) firstname.lastname@example.org
Purchasing Vendor Profile Questionnaire/Diversity Classification Form
services this company
Legal Structure (Check one)
Diversity Classifications (Check all that Apply)
Is the owner(s) of this business a US citizen(s)?
Is this business certified as a Minority Business Enterprise (MBE)?
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:
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.