COMPANY NAME, MAILING ADDRESS                                                         # OF EMPLOYEES
AND CONTACT PERSON
_____________________________________                                                 ____ 20 OR FEWER

_____________________________________                                                 ____ 21 to 50

_____________________________________                                                 ____ 51 to 100

_____________________________________                                                 ____ OVER 100

TELEPHONE # (____) -______________                     FAX # (____) -______________

OWNERSHIP

Minority Owned             YES [   ]     NO [   ]  (51% or more owned and operated by minorities) Are you a minority registered vendor in New Jersey Yes ________ No ___________ If yes Registration # ________________________

Female Owned             YES [   ]     NO [   ]  (51% or more owned and operated by a female) Are you a minority registered vendor in New Jersey Yes ________ No ___________ If yes Registration # ________________________

Does your company have an office located in Atlantic County?    YES [   ]       NO [   ]
If yes please include location __________________________________________________

Does your company currently have any contracts with the State of New Jersey?    YES [   ]       NO [   ]
If yes, please state the commodity and contract number

Commodity ______________________________________________ Contract # __________________

Commodity ______________________________________________ Contract # __________________

Please list the commodity(ies) or service(s) you are interested in providing to Atlantic County.
___________________________________________________________________________________

___________________________________________________________________________________

CONTACT Name and Title   ______________________ EMAIL Address ________________________