Ceridian HR Services Supplier Qualification Form

: Status as a "small" business is based on receipts (total income plus cost of goods sold) or based on total number of employees. Small business is defined pursuant to Section 3 of the Small Business Act (SBA) and relevant regulations issued pursuant thereto. Generally, this means a small business concern organized for profit, which is independently owned and operated, is not dominant in the field of operation in which it is bidding and meets the size standards as prescribed in government regulation. Consult your regional or district SBA office if further clarification is needed. The term "minority-owned" shall mean a business that is (1) at least 51 percent owned by one or more minority individuals or in the case of a publicly owned business, at least 51 percent of the stock of which is owned by one or more minority individuals and (2) whose management and daily business operations are controlled by members of a socially disadvantaged racial/ethnic group. African Americans, Hispanic Americans, Asian Pacific Americans, Subcontinent Asian Americans, and Native Americans and members of other socially disadvantaged groups as designated by the Small Business Act (SBA) are presumed to qualify.

Select all that apply:

HUB Zone Small Business (HUBZone)

: HUBZone is an area located within one or more qualified census tracts, qualified non-metropolitan counties, or lands within the external boundaries of an Indian reservation. This requires certification by the SBA.

Veteran-Owned

: A Veteran-Owned business is a business that is at least 51% owned and controlled by one or more veterans responsible for the financial, operational and administrative functions of the company. A veteran is defined as a US citizen that has served in the active military, naval or air service, and who was discharged or released under conditions other than dishonorable.

Service-Disabled Veteran-Owned

: A Service-Disabled Veteran-Owned business is a business that is at least 51% owned and controlled by one or more service-disabled veterans responsible for the financial, operational and administrative functions of the company. A veteran is defined as a US citizen that has served in the active military, naval or air service, and who was discharged or released under conditions other than dishonorable. A service-disabled veteran is a veteran with a disability that is service connected.

Economically Disadvantaged

: The business owner is certified as being economically disadvantaged. Under the SBA, in order to be considered "economically disadvantaged," an individual must have a net worth of less than $750,000, excluding the equity of the business and primary residence. This requires certification by the SBA.

Physically Challenged Business

: To qualify as a physically challenged business or Disabled Business Enterprise (DBE) a business must be either: A) at least 51% owned by one or more physically challenged individuals, B) a subsidiary that is wholly owned by a parent corporation with at least 51% of the parent corporation voting stock owned by one or more physically challenged individuals, or C) a joint venture in which at least 51% of the management, control and earnings are held by one or more physically challenged individuals.

: Status as a "small" business is based on receipts (total income plus cost of goods sold) or based on total number of employees. Small business is defined pursuant to Section 3 of the Small Business Act (SBA) and relevant regulations issued pursuant thereto. Generally, this means a small business concern organized for profit, which is independently owned and operated, is not dominant in the field of operation in which it is bidding and meets the size standards as prescribed in government regulation. Consult your regional or district SBA office if further clarification is needed. The term "minority-owned" shall mean a business that is (1) at least 51 percent owned by one or more minority individuals or in the case of a publicly owned business, at least 51 percent of the stock of which is owned by one or more minority individuals and (2) whose management and daily business operations are controlled by members of a socially disadvantaged racial/ethnic group. African Americans, Hispanic Americans, Asian Pacific Americans, Subcontinent Asian Americans, and Native Americans and members of other socially disadvantaged groups as designated by the Small Business Act (SBA) are presumed to qualify. In addition, this business is owned and controlled by women members of the listed racial/ethnic groups.

Select all that apply:

HUB Zone Small Business (HUBZone)

: HUBZone is an area located within one or more qualified census tracts, qualified non-metropolitan counties, or lands within the external boundaries of an Indian reservation. This requires certification by the SBA.

Veteran-Owned

: A Veteran-Owned business is a business that is at least 51% owned and controlled by one or more veterans responsible for the financial, operational and administrative functions of the company. A veteran is defined as a US citizen that has served in the active military, naval or air service, and who was discharged or released under conditions other than dishonorable.

Service-Disabled Veteran-Owned

: A Service-Disabled Veteran-Owned business is a business that is at least 51% owned and controlled by one or more service-disabled veterans responsible for the financial, operational and administrative functions of the company. A veteran is defined as a US citizen that has served in the active military, naval or air service, and who was discharged or released under conditions other than dishonorable. A service-disabled veteran is a veteran with a disability that is service connected.

Economically Disadvantaged

: The business owner is certified as being economically disadvantaged. Under the SBA, in order to be considered "economically disadvantaged," an individual must have a net worth of less than $750,000, excluding the equity of the business and primary residence. This requires certification by the SBA.

Physically Challenged Business

: To qualify as a physically challenged business or Disabled Business Enterprise (DBE) a business must be either: A) at least 51% owned by one or more physically challenged individuals, B) a subsidiary that is wholly owned by a parent corporation with at least 51% of the parent corporation voting stock owned by one or more physically challenged individuals, or C) a joint venture in which at least 51% of the management, control and earnings are held by one or more physically challenged individuals.

: This business is owned and controlled by non-minority women. The term "small" shall mean a business defined pursuant to Section 3 of the Small Business Act (SBA) and relevant regulations issued pursuant thereto. Generally, this means a small business concern organized for profit, which is independently owned and operated, is not dominant in the field of operation in which it is bidding and meets the size standards as prescribed in government regulation. Consult your regional or district SBA office if further clarification is needed.

Select all that apply:

HUB Zone Small Business (HUBZone)

: HUBZone is an area located within one or more qualified census tracts, qualified non-metropolitan counties, or lands within the external boundaries of an Indian reservation. This requires certification by the SBA.

Veteran-Owned

: A Veteran-Owned business is a business that is at least 51% owned and controlled by one or more veterans responsible for the financial, operational and administrative functions of the company. A veteran is defined as a US citizen that has served in the active military, naval or air service, and who was discharged or released under conditions other than dishonorable.

Service-Disabled Veteran-Owned

: A Service-Disabled Veteran-Owned business is a business that is at least 51% owned and controlled by one or more service-disabled veterans responsible for the financial, operational and administrative functions of the company. A veteran is defined as a US citizen that has served in the active military, naval or air service, and who was discharged or released under conditions other than dishonorable. A service-disabled veteran is a veteran with a disability that is service connected.

Economically Disadvantaged

: The business owner is certified as being economically disadvantaged. Under the SBA, in order to be considered "economically disadvantaged," an individual must have a net worth of less than $750,000, excluding the equity of the business and primary residence. This requires certification by the SBA.

Physically Challenged Business

: To qualify as a physically challenged business or Disabled Business Enterprise (DBE) a business must be either: A) at least 51% owned by one or more physically challenged individuals, B) a subsidiary that is wholly owned by a parent corporation with at least 51% of the parent corporation voting stock owned by one or more physically challenged individuals, or C) a joint venture in which at least 51% of the management, control and earnings are held by one or more physically challenged individuals.

: Status as a "small" business is based on receipts (total income plus cost of goods sold) or based on total number of employees. Small business is defined pursuant to Section 3 of the Small Business Act (SBA) and relevant regulations issued pursuant thereto. Generally, this means a small business concern organized for profit, which is independently owned and operated, is not dominant in the field of operation in which it is bidding and meets the size standards as prescribed in government regulation. Consult your regional or district SBA office if further clarification is needed. This business is not owned and operated by women or members of a minority group.

Select all that apply:

HUB Zone Small Business (HUBZone)

: HUBZone is an area located within one or more qualified census tracts, qualified non-metropolitan counties, or lands within the external boundaries of an Indian reservation. This requires certification by the SBA.

Veteran-Owned

: A Veteran-Owned business is a business that is at least 51% owned and controlled by one or more veterans responsible for the financial, operational and administrative functions of the company. A veteran is defined as a US citizen that has served in the active military, naval or air service, and who was discharged or released under conditions other than dishonorable.

Service-Disabled Veteran-Owned

: A Service-Disabled Veteran-Owned business is a business that is at least 51% owned and controlled by one or more service-disabled veterans responsible for the financial, operational and administrative functions of the company. A veteran is defined as a US citizen that has served in the active military, naval or air service, and who was discharged or released under conditions other than dishonorable. A service-disabled veteran is a veteran with a disability that is service connected.

Economically Disadvantaged

: The business owner is certified as being economically disadvantaged. Under the SBA, in order to be considered "economically disadvantaged," an individual must have a net worth of less than $750,000, excluding the equity of the business and primary residence. This requires certification by the SBA.

Physically Challenged Business

: To qualify as a physically challenged business or Disabled Business Enterprise (DBE) a business must be either: A) at least 51% owned by one or more physically challenged individuals, B) a subsidiary that is wholly owned by a parent corporation with at least 51% of the parent corporation voting stock owned by one or more physically challenged individuals, or C) a joint venture in which at least 51% of the management, control and earnings are held by one or more physically challenged individuals.

: The term "minority-owned" shall mean a business that is (1) at least 51 percent owned by one or more minority individuals or in the case of a publicly owned business, at least 51 percent of the stock of which is owned by one or more minority individuals and (2) whose management and daily business operations are controlled by members of a socially disadvantaged racial/ethnic group. African Americans, Hispanic Americans, Asian Pacific Americans, Subcontinent Asian Americans, and Native Americans and members of other socially disadvantaged groups as designated by the Small Business Act (SBA) are presumed to qualify. The term "large" shall mean a business that exceeds the small business size code standards established by the Small Business Administration as set forth in the Code of Federal Regulations, Title 13, Part 121.

Select all that apply:

Physically Challenged Business

: To qualify as a physically challenged business or Disabled Business Enterprise (DBE) a business must be either: A) at least 51% owned by one or more physically challenged individuals, B) a subsidiary that is wholly owned by a parent corporation with at least 51% of the parent corporation voting stock owned by one or more physically challenged individuals, or C) a joint venture in which at least 51% of the management, control and earnings are held by one or more physically challenged individuals.

: The term "minority-owned" shall mean a business that is (1) at least 51 percent owned by one or more minority individuals or in the case of a publicly owned business, at least 51 percent of the stock of which is owned by one or more minority individuals and (2) whose management and daily business operations are controlled by members of a socially disadvantaged racial/ethnic group. African Americans, Hispanic Americans, Asian Pacific Americans, Subcontinent Asian Americans, and Native Americans and members of other socially disadvantaged groups as designated by the Small Business Act (SBA) are presumed to qualify. In addition, this business is owned and controlled by women members of the listed racial/ethnic groups. The term "large" shall mean a business that exceeds the small business size code standards established by the Small Business Administration as set forth in the Code of Federal Regulations, Title 13, Part 121.

Select all that apply:

Physically Challenged Business

: To qualify as a physically challenged business or Disabled Business Enterprise (DBE) a business must be either: A) at least 51% owned by one or more physically challenged individuals, B) a subsidiary that is wholly owned by a parent corporation with at least 51% of the parent corporation voting stock owned by one or more physically challenged individuals, or C) a joint venture in which at least 51% of the management, control and earnings are held by one or more physically challenged individuals.

: This business is owned and controlled by non-minority women. The term "large" shall mean a business that exceeds the small business size code standards established by the Small Business Administration as set forth in the Code of Federal Regulations, Title 13, Part 121.

Select all that apply:

Physically Challenged Business

: To qualify as a physically challenged business or Disabled Business Enterprise (DBE) a business must be either: A) at least 51% owned by one or more physically challenged individuals, B) a subsidiary that is wholly owned by a parent corporation with at least 51% of the parent corporation voting stock owned by one or more physically challenged individuals, or C) a joint venture in which at least 51% of the management, control and earnings are held by one or more physically challenged individuals.

: To qualify as a physically challenged business or Disabled Business Enterprise(DBE) a business must be either: A) at least 51% owned by one or more physically challenged individuals, B) a subsidiary that is wholly owned by a parent corporation with at least 51% of the parent corporation voting stock owned by one or more physically challenged individuals, or C) a joint venture in which at least 51% of the management, control and earnings are held by one or more physically challenged individuals. The term "large" shall mean a business that exceeds the small business size code standards established by the Small Business Administration as set forth in the Code of Federal Regulations, Title 13, Part 121.

The fields marked with an * below are required fields and must be completed before you can submit this form. If you have any questions while completing this form you can contact us at purchasing@ceridian.com.

Company Services / Products: *
Commodities or Services your company provides: *
Legal Name of Company/Individual: *
Your Email Address: *
Telephone: *
Sic Code:
Tax ID Number/SS# Individual: *
D&B Number:

Type of Business

		Proprietorship Partnership Corporation Government Military Name of Owner: Please use this link to access the IRS website and complete a W-9 for 1099 purposes http://www.irs.gov/pub/irs-pdf/fw9.pdf. When completed fax form to (440) 838-3548. List Partners: State incorporated and if publicly traded provide symbol:
Number of Years/Business: *
Number Employees:

Home Office Information

Address: *	City: *	State: *
Zip: *

Address:	City:	State:
Zip:

Website Address:

Single Point of Contact
Name: *
Title: *
Telephone: *
Email Address: *

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Online Supplier Registration Form

Your Company Information
Products and/or Services your company provides: * (Please keep to one paragraph and don't use line returns.)
Have you provided products or services to Ceridian or affiliates previously? *	Yes No
If yes, give brief description and location. (Please keep comments to one paragraph and don't use line returns.)
Does your firm maintain all necessary licenses to conduct business? *	Yes No
Do you maintain the necessary insurance on your personnel should they be required to enter Ceridian premises? *	Yes No

Payment Terms - NET 30? *	Yes No If No, what are payment terms?

EEO Compliance Certification
A. Has or will your company file the required employer information report EEO-1 (standard form 100) with the secretary of labor's joint reporting committee for the last calendar year by the required filing date?	Yes No Please check the following appropriate reason for not filing: 1. Employ less than 100 people 2. Have not received any of the following: a) Prime contract of first-tier sub-contracts for $50,000 or more b) Any tier construction contract for $50,000 or more 3. Have specific exemption from secretary of labor as provided in section 204 of executive order 11246 as amended by E.O. 11375

B. Do you have at each of your facilities a written affirmative action compliance program as called for in 60-2.40 and 60-2 (revised order 4) of title 41 of the code of federal regulations?	Yes No Is it current Yes No Within 20 days after receipt of any order of $50,000 or more from Ceridian, the contractor, if it has fifty (50) or more emaployees and is not otherwise exempt by the law or regulations, agrees to develop an affirmative action compliance program for each of its facilities.

C. Seller has has not held contracts or sub-contracts subject to the equal opportunity clause of executive order 11246, as amended by E.O. 11375

Conflict of Interest Statement
Do you have any family, business, or financial relationship with any employees, subcontractors, partners or competitors of Ceridian? *	Yes No Details/additional comments:

Ceridian Supplier Diversity Sign-up
If your company falls into one of the following business classifications it is necessary to continue the registration process by selecting your classification information. This will be used by Ceridian solely for monitoring supplier classifications, developing and improving our supplier diversity programs, and filing governmental reports as may be required by applicable regulations.

If you require assistance in understanding these categories, you are encouraged to visit the following sites or agencies for additional information: Small Business Administration (http://www.sba.gov/) National Minority Supplier Development Council (http://www.nmsdcus.org/) Women's Business Enterprise National Council (http://www.wbenc.org/)

NOTE: If you are a large business and are not classified in any of the categories below there is no further response necessary. Scroll to the bottom of this form and submit.

Are you certified (by the US Small Business Administration or another certifying agency) in one of the business classifications described below?	Yes No Please provide the following information: Certification Number (if applicable): State Certification was Issued: Expiration Date (MM/DD/YYYY): Please continue to register by selecting a business classification from the list below. Please continue to register by selecting a BUSINESS CLASSIFICATION from the list below.

Choose only one business classification from the list below: *
Small Minority Owned Business Status as a "small" business is based on receipts (total income plus cost of goods sold) or based on total number of employees. Small business is defined pursuant to Section 3 of the Small Business Act (SBA) and relevant regulations issued pursuant thereto. Generally, this means a small business concern organized for profit, which is independently owned and operated, is not dominant in the field of operation in which it is bidding and meets the size standards as prescribed in government regulation. Consult your regional or district SBA office if further clarification is needed. The term "minority-owned" shall mean a business that is (1) at least 51 percent owned by one or more minority individuals or in the case of a publicly owned business, at least 51 percent of the stock of which is owned by one or more minority individuals and (2) whose management and daily business operations are controlled by members of a socially disadvantaged racial/ethnic group. African Americans, Hispanic Americans, Asian Pacific Americans, Subcontinent Asian Americans, and Native Americans and members of other socially disadvantaged groups as designated by the Small Business Act (SBA) are presumed to qualify. Select all that apply: HUB Zone Small Business (HUBZone) HUBZone is an area located within one or more qualified census tracts, qualified non-metropolitan counties, or lands within the external boundaries of an Indian reservation. This requires certification by the SBA. Veteran-Owned A Veteran-Owned business is a business that is at least 51% owned and controlled by one or more veterans responsible for the financial, operational and administrative functions of the company. A veteran is defined as a US citizen that has served in the active military, naval or air service, and who was discharged or released under conditions other than dishonorable. Service-Disabled Veteran-Owned A Service-Disabled Veteran-Owned business is a business that is at least 51% owned and controlled by one or more service-disabled veterans responsible for the financial, operational and administrative functions of the company. A veteran is defined as a US citizen that has served in the active military, naval or air service, and who was discharged or released under conditions other than dishonorable. A service-disabled veteran is a veteran with a disability that is service connected. Economically Disadvantaged The business owner is certified as being economically disadvantaged. Under the SBA, in order to be considered "economically disadvantaged," an individual must have a net worth of less than $750,000, excluding the equity of the business and primary residence. This requires certification by the SBA. Physically Challenged Business To qualify as a physically challenged business or Disabled Business Enterprise (DBE) a business must be either: A) at least 51% owned by one or more physically challenged individuals, B) a subsidiary that is wholly owned by a parent corporation with at least 51% of the parent corporation voting stock owned by one or more physically challenged individuals, or C) a joint venture in which at least 51% of the management, control and earnings are held by one or more physically challenged individuals. Small Minority Women Owned Business Status as a "small" business is based on receipts (total income plus cost of goods sold) or based on total number of employees. Small business is defined pursuant to Section 3 of the Small Business Act (SBA) and relevant regulations issued pursuant thereto. Generally, this means a small business concern organized for profit, which is independently owned and operated, is not dominant in the field of operation in which it is bidding and meets the size standards as prescribed in government regulation. Consult your regional or district SBA office if further clarification is needed. The term "minority-owned" shall mean a business that is (1) at least 51 percent owned by one or more minority individuals or in the case of a publicly owned business, at least 51 percent of the stock of which is owned by one or more minority individuals and (2) whose management and daily business operations are controlled by members of a socially disadvantaged racial/ethnic group. African Americans, Hispanic Americans, Asian Pacific Americans, Subcontinent Asian Americans, and Native Americans and members of other socially disadvantaged groups as designated by the Small Business Act (SBA) are presumed to qualify. In addition, this business is owned and controlled by women members of the listed racial/ethnic groups. Select all that apply: HUB Zone Small Business (HUBZone) HUBZone is an area located within one or more qualified census tracts, qualified non-metropolitan counties, or lands within the external boundaries of an Indian reservation. This requires certification by the SBA. Veteran-Owned A Veteran-Owned business is a business that is at least 51% owned and controlled by one or more veterans responsible for the financial, operational and administrative functions of the company. A veteran is defined as a US citizen that has served in the active military, naval or air service, and who was discharged or released under conditions other than dishonorable. Service-Disabled Veteran-Owned A Service-Disabled Veteran-Owned business is a business that is at least 51% owned and controlled by one or more service-disabled veterans responsible for the financial, operational and administrative functions of the company. A veteran is defined as a US citizen that has served in the active military, naval or air service, and who was discharged or released under conditions other than dishonorable. A service-disabled veteran is a veteran with a disability that is service connected. Economically Disadvantaged The business owner is certified as being economically disadvantaged. Under the SBA, in order to be considered "economically disadvantaged," an individual must have a net worth of less than $750,000, excluding the equity of the business and primary residence. This requires certification by the SBA. Physically Challenged Business To qualify as a physically challenged business or Disabled Business Enterprise (DBE) a business must be either: A) at least 51% owned by one or more physically challenged individuals, B) a subsidiary that is wholly owned by a parent corporation with at least 51% of the parent corporation voting stock owned by one or more physically challenged individuals, or C) a joint venture in which at least 51% of the management, control and earnings are held by one or more physically challenged individuals. Women-Owned Small Business (Non-Minority) This business is owned and controlled by non-minority women. The term "small" shall mean a business defined pursuant to Section 3 of the Small Business Act (SBA) and relevant regulations issued pursuant thereto. Generally, this means a small business concern organized for profit, which is independently owned and operated, is not dominant in the field of operation in which it is bidding and meets the size standards as prescribed in government regulation. Consult your regional or district SBA office if further clarification is needed. Select all that apply: HUB Zone Small Business (HUBZone) HUBZone is an area located within one or more qualified census tracts, qualified non-metropolitan counties, or lands within the external boundaries of an Indian reservation. This requires certification by the SBA. Veteran-Owned A Veteran-Owned business is a business that is at least 51% owned and controlled by one or more veterans responsible for the financial, operational and administrative functions of the company. A veteran is defined as a US citizen that has served in the active military, naval or air service, and who was discharged or released under conditions other than dishonorable. Service-Disabled Veteran-Owned A Service-Disabled Veteran-Owned business is a business that is at least 51% owned and controlled by one or more service-disabled veterans responsible for the financial, operational and administrative functions of the company. A veteran is defined as a US citizen that has served in the active military, naval or air service, and who was discharged or released under conditions other than dishonorable. A service-disabled veteran is a veteran with a disability that is service connected. Economically Disadvantaged The business owner is certified as being economically disadvantaged. Under the SBA, in order to be considered "economically disadvantaged," an individual must have a net worth of less than $750,000, excluding the equity of the business and primary residence. This requires certification by the SBA. Physically Challenged Business To qualify as a physically challenged business or Disabled Business Enterprise (DBE) a business must be either: A) at least 51% owned by one or more physically challenged individuals, B) a subsidiary that is wholly owned by a parent corporation with at least 51% of the parent corporation voting stock owned by one or more physically challenged individuals, or C) a joint venture in which at least 51% of the management, control and earnings are held by one or more physically challenged individuals. Small Business (Non-Minority Owned; Non-Women Owned) Status as a "small" business is based on receipts (total income plus cost of goods sold) or based on total number of employees. Small business is defined pursuant to Section 3 of the Small Business Act (SBA) and relevant regulations issued pursuant thereto. Generally, this means a small business concern organized for profit, which is independently owned and operated, is not dominant in the field of operation in which it is bidding and meets the size standards as prescribed in government regulation. Consult your regional or district SBA office if further clarification is needed. This business is not owned and operated by women or members of a minority group. Select all that apply: HUB Zone Small Business (HUBZone) HUBZone is an area located within one or more qualified census tracts, qualified non-metropolitan counties, or lands within the external boundaries of an Indian reservation. This requires certification by the SBA. Veteran-Owned A Veteran-Owned business is a business that is at least 51% owned and controlled by one or more veterans responsible for the financial, operational and administrative functions of the company. A veteran is defined as a US citizen that has served in the active military, naval or air service, and who was discharged or released under conditions other than dishonorable. Service-Disabled Veteran-Owned A Service-Disabled Veteran-Owned business is a business that is at least 51% owned and controlled by one or more service-disabled veterans responsible for the financial, operational and administrative functions of the company. A veteran is defined as a US citizen that has served in the active military, naval or air service, and who was discharged or released under conditions other than dishonorable. A service-disabled veteran is a veteran with a disability that is service connected. Economically Disadvantaged The business owner is certified as being economically disadvantaged. Under the SBA, in order to be considered "economically disadvantaged," an individual must have a net worth of less than $750,000, excluding the equity of the business and primary residence. This requires certification by the SBA. Physically Challenged Business To qualify as a physically challenged business or Disabled Business Enterprise (DBE) a business must be either: A) at least 51% owned by one or more physically challenged individuals, B) a subsidiary that is wholly owned by a parent corporation with at least 51% of the parent corporation voting stock owned by one or more physically challenged individuals, or C) a joint venture in which at least 51% of the management, control and earnings are held by one or more physically challenged individuals. Minority Owned Large Business The term "minority-owned" shall mean a business that is (1) at least 51 percent owned by one or more minority individuals or in the case of a publicly owned business, at least 51 percent of the stock of which is owned by one or more minority individuals and (2) whose management and daily business operations are controlled by members of a socially disadvantaged racial/ethnic group. African Americans, Hispanic Americans, Asian Pacific Americans, Subcontinent Asian Americans, and Native Americans and members of other socially disadvantaged groups as designated by the Small Business Act (SBA) are presumed to qualify. The term "large" shall mean a business that exceeds the small business size code standards established by the Small Business Administration as set forth in the Code of Federal Regulations, Title 13, Part 121. Select all that apply: Physically Challenged Business To qualify as a physically challenged business or Disabled Business Enterprise (DBE) a business must be either: A) at least 51% owned by one or more physically challenged individuals, B) a subsidiary that is wholly owned by a parent corporation with at least 51% of the parent corporation voting stock owned by one or more physically challenged individuals, or C) a joint venture in which at least 51% of the management, control and earnings are held by one or more physically challenged individuals. Minority Women Owned Large Business The term "minority-owned" shall mean a business that is (1) at least 51 percent owned by one or more minority individuals or in the case of a publicly owned business, at least 51 percent of the stock of which is owned by one or more minority individuals and (2) whose management and daily business operations are controlled by members of a socially disadvantaged racial/ethnic group. African Americans, Hispanic Americans, Asian Pacific Americans, Subcontinent Asian Americans, and Native Americans and members of other socially disadvantaged groups as designated by the Small Business Act (SBA) are presumed to qualify. In addition, this business is owned and controlled by women members of the listed racial/ethnic groups. The term "large" shall mean a business that exceeds the small business size code standards established by the Small Business Administration as set forth in the Code of Federal Regulations, Title 13, Part 121. Select all that apply: Physically Challenged Business To qualify as a physically challenged business or Disabled Business Enterprise (DBE) a business must be either: A) at least 51% owned by one or more physically challenged individuals, B) a subsidiary that is wholly owned by a parent corporation with at least 51% of the parent corporation voting stock owned by one or more physically challenged individuals, or C) a joint venture in which at least 51% of the management, control and earnings are held by one or more physically challenged individuals. Women-Owned Large Business (Non-Minority) This business is owned and controlled by non-minority women. The term "large" shall mean a business that exceeds the small business size code standards established by the Small Business Administration as set forth in the Code of Federal Regulations, Title 13, Part 121. Select all that apply: Physically Challenged Business To qualify as a physically challenged business or Disabled Business Enterprise (DBE) a business must be either: A) at least 51% owned by one or more physically challenged individuals, B) a subsidiary that is wholly owned by a parent corporation with at least 51% of the parent corporation voting stock owned by one or more physically challenged individuals, or C) a joint venture in which at least 51% of the management, control and earnings are held by one or more physically challenged individuals. Large Business Owned by Physically Challenged (Non-Minority Owned; Non-Women Owned) To qualify as a physically challenged business or Disabled Business Enterprise(DBE) a business must be either: A) at least 51% owned by one or more physically challenged individuals, B) a subsidiary that is wholly owned by a parent corporation with at least 51% of the parent corporation voting stock owned by one or more physically challenged individuals, or C) a joint venture in which at least 51% of the management, control and earnings are held by one or more physically challenged individuals. The term "large" shall mean a business that exceeds the small business size code standards established by the Small Business Administration as set forth in the Code of Federal Regulations, Title 13, Part 121. Historically Black Colleges & Universities and Minority Institutions An accredited institution of higher education that was established before 1964; has a principal mission that was, and is, the education of Black Americans; and, as determined by the Secretary of Education, meets the regulations set forth by the U.S. Department of Education. Any non-profit research institute that was an integral part of an Historically Black College or University before November 14, 1986 is also included in this definition.

By selecting to submit this form you are acknowledging that all of the information you have provided is true; that you will not ship equipment, product or services without receiving a purchase order number; and that you agree to reference the p.o. number on all packing slips and invoices.