Diversity

Minority and Women-Owned Supplier Survey

Fields marked with an asterick(*) are required.

Supplier Information Supplier Number Supplier Name*: Supplier Address 1*: Supplier Address2: City*: State/Province*: Zip/Province Code*: Country*: Email*: Website Address: Federal ID Number(or SSN and Name)*: Sales Contact*: Phone:* Fax:* Principle Owner's Name*: Phone:* Fax:* Year Established:* Annual Sales:* Geographic Preferences/Limitations:* Number of Employees:* Business Activity Check one or more if applicable     SIC # Manufacturer Distibutor Contractor     Consultant     Manufacturer's Rep       Describe your products and/or services*   Has your company done business with Bayer Corporation before ?* Yes     No   If yes, please list business units and individuals contacted     Notice: All contractors and subcontractors who are guilty of false representation will be subject to penalties, as required by 15 U.S.C. 654(d) and FAR 52.219-9(e)(4). Supplier Classification Check one from each category Gender* Woman Owned Other   Challenge* SDB - Socially Disadvantaged Business SDB/HubZone Disabled SDB/Service Disabled Veteran SDB/HubZone/Service Disabled Veteran HubZone SDB/HubZone/Veteran Service Disabled Veteran Service Disabled Veteran/HubZone Veteran Veteran/HubZone Unclassified   Ethnicity* Native American African American Caucasian Hispanic American Subcontinent Asian American Minority Unclassified Non-Minority Asian Pacific American Certified By & Certification Numbers Check one or more if applicable. If you are certified by any of the agencies below, or any other agency, please provide a copy of your current certification papers to: Laura Lapiska, Bayer Corporation, 100 Bayer Road, Pittsburgh, PA, 15205-9741; FAX 412.777.7533, e-mail  bayer.supplierdiversity@bayer.com Agency Certification # SBA NMSDC MBDA Regional Council Please Specify:  Other Please Specify:  HubZone WBENC Completed By*: Name/Title*: