Supplier Registration Form

Bold = Required field
 
Section 1. Business Information
 
Company Information
Legal Company Name:
List any company names under which the present company you are registering may have operated under in the past.
Headquarters Physical Address:  
Physical Address (Cont.):
City:
State / Region:
Zip / Postal Code:
Country:
Phone Number:  
Fax Number:
Web Site Address (URL):  
 
Business Type (Select one or more)
Is your company Minority Owned?
If your company is Minority Owned please define:
Is your company a Women-Owned Business Enterprise?
Is your company a co-op or publicly traded?
Is your company a broker, co-packer or manufacturer?
 
Principal Owner Information
This information is not required if you indicate that your company is a co-op or publicly traded.
Principal Owner is a US citizen?
Name: Title: Email: Gender: Owner Ethnicity: % Ownership:
 
Primary Contact Information
Primary Contact Name: First/Last Name
Title:  
Mailing Address is same as Headquarters Address
Mailing Address:  
Mailing Address (Cont.):
City:  
State / Region:    
Zip / Postal Code:
Country:  
Phone Number:   Ext.
Fax Number:  
Email Address:  
Are you a current supplier to Carlson?
If yes, what Carlson Business Unit(s) are you working with?
Annual Sales to Carlson:
Numbers only, no comma or decimal point
(e.g., 3000000).
Carlson Contact Name:
Phone Number: Ext.
 
Company Data
Legal Structure:
Annual Revenue (Last fiscal year):
Numbers only, no comma or decimal point
(e.g., 3000000).
Geographical Service Area:
Year Business was Established:  
Number of Employees:  
Number of Customers:
Insurance Coverage:
CTRL-click to select multiple insurances. 		 
DUN and Bradstreet Number:
Search or Request a D-U-N-S number
 
Section II. Business Certification
 
Certification
Is your business presently certified as a MWBE with the National Minority Supplier Development Council (or local affiliate), Women's Business Enterprise National Council (or local affiliate), National Women's Business Owners Corporation, government agency; or California Public Utility?



If no, skip to Section III.
If your company is certified as MWBE, please list the certifying agency, and upload a copy of your certification.
Certification Agency (1):  
Certification Type (1):  
Expiration Date (1): (mm/dd/yyyy) 
Upload Certificate (1): < 1 MB
Certification Agency (2):
Certification Type (2):
Expiration Date (2): (mm/dd/yyyy)
Upload Certificate (2): < 1 MB
 
Section III. QA & Food Safety Standards
Which third party auditors do you use for verifying compliance for Quality Assurance & Food Safety Standards?
 
Section IV. Products and/or Services
Service/Specialty (1):
Service/Specialty (2):
Service/Specialty (3):
 
Enter additional information describing your business specialty, services and/or products (up to 500 characters):
 
References
List current business customer(s) (local or otherwise) which have been or are now your customer(s):
Company Name: Contact Name: Phone Number:
 
Section V. e-Business Readiness
Do you have an online Catalog? Can you sell your products/services online?
Are you Electronic Data Interchange (EDI) capable? Do you accept payment by credit card?
By choosing to submit this form, you certify that the information you have provided above is true and accurate. The intent of this form is to gather information and not a commitment to award any business with the registrant.

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