Supplier Diversity Registration

Fields outlined in orange are required.

Seton’s Vendor # or Contract #, if applicable:

Name of business:

Please give us a brief description of your business:

Contact person and title:

Physical address:

City:

State:

Zip Code:

Business telephone number: (xxx-xxx-xxxx)

Fax: (xxx-xxx-xxxx)

Cell number: (xxx-xxx-xxxx)

Pager: (xxx-xxx-xxxx)

Please list the Minority Certifying Identifier that best describes your business from the following list: African American Female
African American Male
Asian Pacific Female
Asian Pacific Male
Hispanic Female
Hispanic Male
Native American Female
Native American Male
Woman-owned Business

...

Please provide certification documentation from CSTMBC or WBENC.

Federal Tax Id#:

NAICS Code(s):

Submitted by

Name:

Title:

Email:

Supplier Diversity Supplier Diversity Registration