Powell Diversity Supplier Registration Form

Company Name

Address

Address 1

Address 2

City

State / Province

ZIP / Postal Code

Supplier Diversity Certification (click on all that apply):

Note: Only those businesses certified by third-party agencies or government agencies will be accepted. Additional Requirements: - The business owners are U.S citizen or legal resident aliens. - The business must be least 51% owned, controlled and managed by one or more members of designated group. - The business must be for-profit and physically located in the United States or its territories.

Minority Owned Business (MBE)

Women Owned Business

Veteran Owned Business

Disabled Veteran Owned Business

Small Disadvantaged Owned Business

Underutilized Business Zone (HUBzone)

U.S Small Business Administration (SBA 8(a))

Contact Name

Contact Title

Contact Email

Contact Phone Number

Company Industry

Company Products/Services Offered

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Office, Manufacturing, and Service Locations.

Located in five countries, Powell has an office, manufacturing facility or service center near you to meet your needs. Contact us to discuss how we can be of service.
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