Supplier Registration : Supplier Diversity : Veolia Water North America

Owner Information

Company Name: *

Salutation:

First Name: *	Middle Name:	Last Name: *

Owner's Title: *

Contact Information

Same as Owner Information:

Salutation:

First Name: *	Middle Name:	Last Name: *

Title: *

Contact's Email: *

Web Site:

Physical Address: *

Suite:

City: *	State: *	ZipCode: *
	(Ex. TX)	-

County: *
(Ex. Harris County)

Mailing Address

Same as Physical Address

Mailing Address:

Suite:

City:	State:	ZipCode:
	(Ex. TX)	-

County:
(Ex. Harris County)
Telephone Number: *
( )- - ext.
Fax Number:
( )- -

Business Information

Type of Organization: *

Please fill in the category that best describes your business. *

Main Commodity:

Sub Commodity:

Main Service:

Sub Service:

If you have entered both a commodity and a service, please specify your 'Primary' category.
Commodity Service

Please use the following link to find your appropriate NAICS code.

North American Industrial Code System (NAICS code): *

Based on your primary NAICS code and the Small Business Administration Standards (SBA) (www.sba.gov/size/indextableofsize.html), the company is:
(Contact SBA at 1-800-8ASK-SBA)

1
	Select the size of your business according to SBA: * Small Business Large Business If "Small Business", are you: (check all that apply) Veteran Owned Service-Disabled Veteran Owned Women Owned
2
	Certified as Small Disadvantaged Business by SBA? * Yes No If yes, Expiration Date of Certification: (mm/dd/yyyy)
3
	Certified as HUBZone by SBA? * Yes No
4
	Are you a Historically Black College/University or Minority Institution? * Yes No

Have you ever done business with Veolia Water North America?
Yes
No
If Yes, when? (Year only)

Do you accept American Express?
Yes
No

In order to qualify as a M/WBE, the company must be 51% owned, operated and controlled by a minority(s) or woman/women. Please check the appropriate classification. *

African American Male	Hispanic Male
African American Female	Hispanic Female
Asian Indian American Male	Native American Male
Asian Indian American Female	Native American Female
Asian Pacific American Male	White Female
Asian Pacific American Female	White Male

Certification Information

Please include your certification information in the following fields:

1

Certification: (e.g. Minority Business Enterprise, etc.)

Agency's Name:

Expiration Date:

2

Certification: (e.g. Minority Business Enterprise, etc.)

Agency's Name:

Expiration Date:

3

Certification: (e.g. Minority Business Enterprise, etc.)

Agency's Name:

Expiration Date:

4

Certification: (e.g. Minority Business Enterprise, etc.)

Agency's Name:

Expiration Date:

Terms and Agreement

We must receive a copy of your certification within 30 days in order to complete your profile. Please forward your information to fax number 317-686-9519, or e-mail supplier.diversity@veoliawaterna.com, or mail to Veolia Water North America, Attn: Supplier Diversity Program, 101 West Washington Street, Suite 1400 East Indianapolis, IN 46204

Information prepared by: *
Name:		Date: 5/17/2012
Title:

Under 15 U.S.C. 645(d), any person who misrepresents a firm's status as a small or small disadvantaged business concern in order to obtain a contract to be awarded under the preference programs established pursuant to section 8(a), 8(d), 9, or 15 of the Small Business Act or any other provision of Federal law that specifically references 8(d) for a definition of program eligibility, shall (i) Be punished by imposition of fine, imprisonment, or both; (ii) Be subject to administrative remedies, including suspension and debarment; and (iii) Be ineligible for participation in programs conducted under the authority of the Act.

Please check this if you have read and understand the 15 U.S.C. 645(d) clause. *