diversity_supplier

Information Form for Supplier Diversity

*Required Field

*Required Field

Employers Name

Employers Name Name of company where you work null

Federal Tax Identification Number

Federal Tax Identification Number Also known as Employer Identification Number null

Your Name

Your Name First and Last Name null

Title

Title Professional title within company null

Email Address

Email Address null

Phone Number

Phone Number ###-###-#### null

Website

Website Company URL null

Date Company Formed

Date Company Formed mm/dd/yyyy null

What diverse supplier certifications do you have? List all that apply.

What diverse supplier certifications do you have? List all that apply. null

Are you a NYS Certified Diverse Supplier

Are you a NYS Certified Diverse Supplier null

Which industry profile best describes your offering? Select all that apply.

Which industry profile best describes your offering? Select all that apply. null

Describe what types of capabilities your company specializes in

Describe what types of capabilities your company specializes in null

Briefly explain why your company is uniquely qualified.

Briefly explain why your company is uniquely qualified. What differentiates you from your competitors. null

Please provide your current client listing and briefly describe the services that are provided. If you are currently working with any other health plans please list those as a priority.

Please provide your current client listing and briefly describe the services that are provided. If you are currently working with any other health plans please list those as a priority.

Current Clients

Current Clients null
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