Supplier Registration

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The Village of Flossmoor is committed to increasing the diversity within our supply chain. Whenever possible, it is our goal to seek pricing or proposals for goods and services from businesses that reflect the diversity of our community. As a step toward that goal, we invite you to create a profile in the Village of Flossmoor supplier registration database. We will use this as a sourcing tool for future RFP and procurement opportunities.

Company Name *

Doing Business As (DBA) Name

Address *

City *

State *

Zip Code *

County *

Telephone Number *

Company Website

Primary Contact Name *

Primary Contact Title *

Primary Contact Email Address *

Date Established *

DUNS Number

NAICS Code

Visit www.census.gov/naics for more information.

Provide a brief description of products or services you provide. *

Number of Employees *

Small or Large Business *

Small Business

Large Business

Check all that apply:

Minority Owned Business

Woman Owned Business

Veteran Owned Business

LGBT Owned Businesses

Disability Owned Business

If any of the above applies, indicate which organization has certified your business.

Certification of Information *

I hereby certify that all the information provided above is true and complete to the best of my knowledge. The undersigned certifies that they are authorized to sign on behalf of the Company listed above and that all the information provided on this form is true and accurate. I (we) understand that misrepresentation may be cause for removal as a qualified vendor along with any penalties allowed by law.

Electronic Signature *

Name *

Title *

Date *

YYYY

Submit

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