Supplier Diversity Registration

Please complete your company profile and contact information below.

Fields marked by * are required.

Company Information
*Company Name:
Company Legal Name:	(if different)
Tax ID:	Federal Tax ID for U.S. Firms, Equivalent Tax Identification for others
Primary SIC Code:	U.S. Firms see: http://www.census.gov/epcd/naics02/
Incorporation Country:	(if applicable)
Incorporation State:	(if incorporated in US) (if applicable)
Are you CPUC Certified?	Yes No If YES, please submit VON number If NO, visit www.asianinc.org for application
Certification Agency:
Headquarter Location:	(City, State or Region, Country)
Company Website Address:
Distributor:	No Yes Is your company a distributor or Value Added Reseller?
Sales Rep:	No Yes Are you representing more than one company?
Describe the products or services that you offer:

Contact Information
*Name:
*Title:
*Telephone:
*Email:
*Address 1:
Address 2:
*City:
*State or Region:
*ZIP or Postal Code:
*Country:
*	Please enter in the word you see in the image