Vendor Information Reporting Form Survey

1.Company Information

Contact Name

Company Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

2.Company Status
(please check all that apply)

Certified Small Business / meets certification requirements as a small business under SBA standards.
*More information and definitions can be found at sba.gov.

Minority-Owned Business – A business which is at least 51% owned by one or more minority persons, or in the case of a corporation, at least 51% of the stock in which is owned by one or more minority persons; and the management and daily business operations of which are controlled by one or more of the minority individuals who own it.

Women-Owned Business – A business which is at least 51% owned by one or more women, or in the case of a corporation, at least 51% of the stock in which is owned by one or more women; and the management and daily business operations of which are controlled by one or more of the women who own it.

Veteran-Owned Business – A small business (i) that is at least 51% owned by one or more qualified veterans living in Illinois or, in the case of a corporation, at least 51% of the stock in which is owned one or more qualified veterans living in Illinois; (ii) that has its home office in Illinois; and (iii) for which items (i) and (ii) are actually verified annually by the Commission on Equity and Inclusion.

None of the above.

Organization is self-certifying.

3.If applicable, list any certifications your organization hold for the previous categories.

Certification #1

Certification #2

Certification #3

Certification #4

Certification #5

4.Upload Your Form W-9
(only PDF files are supported)

Form W-9 may also be mailed to Northbrook Park District, 545 Academy Drive, Northbrook, IL. 60062.

No file chosen