Supplier Diversity Program

Supplier Diversity Program Vendor Profile

NEW YORK POWER AUTHORITY SUPPLIER DIVERSITY PROGRAM
VENDOR PROFILE (en español)	1. TYPE OF RESPONSE ____Initial ____Revision	2. DATE
NOTE: Complete all items on this form. Insert N/A in items not applicable. Please include company literature or brochure with this form.
3. NAME AND ADDRESS OF NYPA ENTITY TO WHICH FORM SUBMITTED New York Power Authority 123 Main Street White Plains, NY 10601-3104 Attention: Contract Administration Division, SDP		4. NAME AND ADDRESS OF APPLICANT (include country and nine-digit ZIP+4)
5. TYPE OF ORGANIZATION (CHECK ONE): _______ Individual _______ Partnership _______ Non-Profit _______ Corporation (Incorporated under the laws of the State of __________)		6. ADDRESS TO WHICH SOLICITATIONS ARE TO BE MAILED (if different than Item 4)
7. NAMES OF OFFICERS, OWNERS OR PARTNERS
A. PRESIDENT	B. VICE PRESIDENT	C. SECRETARY
D. TREASURER	E. OWNERS OR PARTNERS
8. AFFILIATES OF APPLICANT (Names, locations, nature of affiliation, etc.)
9. IDENTIFY EQUIPMENT, SUPPLIES, AND/OR SERVICES ON WHICH YOU DESIRE TO MAKE AN OFFER (Provide SIC Codes, if available)
10. SIZE OF BUSINESS _______ Small Business _______ Other than Small Business	11. AVERAGE NUMBER OF EMPLOYEES (including affiliates) FOR FOUR PRECEDING QUARTERS (Add "/P" if for Parent Company) ________ AS OF _____/_____/_____ MO/DAY/YR	12. AVERAGE SALES OR RECEIPTS FOR PRECEDING THREE FISCAL YEARS (Add "/P" if for Parent Company) $________________AS OF _____/_____/_____ MO/DAY/YR
13. TYPE OF OWNERSHIP (See definitions in NYPA Guide) ________ Minority Business Enterprise ________ Women-Owned Business Enterprise NYS M/WBE Certification No. __________________________	14. TYPE OF BUSINESS ________ Manufacturer/Producer ________ Manufacturing Representative ________ Service Establishment ________ Consultant (Personal Services) ________ Regular Dealer ________ Surplus Dealer ________ Construction Concern
15. DUNS NO. (If available)	16. YEAR BUSINESS FORMED? (Add "/P" if year Parent Company formed)
17. PAYEE IDENTIFICATION NUMBERS A. FEDERAL SOCIAL SECURITY ACCOUNT NUMBER: _______________ B. FEDERAL EMPLOYER ID NUMBER: _____________________________
18. COLLECTIVE BARGAINING AGREEMENTS (List of locals and Trades, if any, with contract expiration dates)	19. LICENSING AGREEMENTS (List any licensing agreements required to provide your product/service, exp. Dates, and whether your business is licensee or licensor)	20. BONDING REFERENCE (List highest bond received, date and bonding reference)
CERTIFICATION: I certify that information supplied herein (including all pages attached) is correct and that neither the applicant nor any person (or concern) in any connection with the applicant as a principal or officer, so far as is known, is now debarred or otherwise declared ineligible by any agency of the State of New York from making offers for furnishing materials, supplies, or services to the State of New York or any agency thereof.
21. Name/Title of Person Authorized to sign (Type or Print)	22. SIGNATURE	23. DATE