Vendor Registration Form

Company/Contact Information

Company Name:
D.B.A. Name:
Business Type/Category:
If Other* category, please enter here:
Tax ID#:
Contact First Name:
Contact Last Name:
Contact Email:
Contact Phone #:
Street Address:
Address 2:
City:
State:
Zip:
Country:
Payment Address (if different from mailing address):
Address 2:
City:
State:
Zip:
Country:
W-9 Form:	Please upload your completed W-9 form
ACH Information:	Please upload your ACH Information

Type of Ownership (no certification required)

Certification(s) - if applicable

Firms must be certified by one of the five entities from which we accept certifications. Currently we accept certifications from the City of Chicago, Cook County Government, the State of Illinois Department of Central Management Services, Chicago Minority Supplier Development Council, and the Women’s Business Development Council. If you are not currently certified, but are interested, you will find links below pointing to certifying agencies that we accept: City of Chicago, Department of Procurement Services Chicago Minority Supplier Development Council(CMSDC) County of Cook Women’s Business Development Center (WBDC) State of Illinois, Central Management Services
Minority Business Enterprises (MBE) Certified:	udf_3819 Yes No
Certificate for MBE:	Please upload your MBE Certification
MBE Certificate Expiration Date:
Women’s Business Enterprises (WBE) Certified:	udf_3818 Yes No
Certificate for WBE:	Please upload your WBE Certification
WBE Certificate Expiration Date:
Other Certification:	Please upload other Certification (BEPD, VBE, LGBTBE) if applicable
Certificate Expiration Date:
Other Certification:	Please upload other Certification (BEPD, VBE, LGBTBE) if applicable
Certificate Expiration Date:

Red fields are required.

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