Supplier Diversity Form

Epstein Becker Green’s Supplier Diversity program recognizes companies that are 51% owned, controlled, and operated by a diverse person(s). Submitting your company’s information to Epstein Becker Green does not guarantee business, but if you are an eligible diverse supplier, you are more likely to be considered if you are in our supplier diversity database.

Epstein Becker Green expects all suppliers with whom we partner with to adhere to our non-discriminatory policy. Suppliers will not discriminate on grounds, including but not limited to, race, color, religion, creed, sex, sexual orientation, gender identity, citizenship status, marital status, genetic information, national origin, age, disability, military or veteran status, or status in any group protected by federal, state, and local law.

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* 1. Company Name:

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* 2. Contact Name:

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* 3. Contact Title:

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* 4. Company Address:

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* 5. Company City, State, and Zip:

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* 6. Telephone Number:

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* 7. Email Address:

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* 8. Company Website / URL:

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* 9. Overview of your company including goods/services offered and company size:

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* 10. Select ALL that apply to your business. If none apply, select N/A at the bottom of the list:

Minority Business Enterprise (MBE) – At least 51 percent minority owned, operated, and controlled by one or more US citizens from one of the following ethnic minority groups: African American, Alaskan Native, Asian Indian American, Asian Pacific American, Hispanic American, Native American.

Women Business Enterprise (WBE) – at least 51 percent owned, controlled, operated, and actively managed by one or more women with US citizenship.

Veteran Owned Business Enterprise (VBE) – at least 51 percent owned by one or more veterans with management and daily business operations controlled by one or more veterans.

Lesbian, Gay, Bisexual, Transgender or Queer Owned Business (LGBTQ) – at least 51 percent owned by lesbian, gay, bisexual, transgender, or queer individuals.

Disability Owned Business Enterprise (DOBE) – at least 51 percent owned, controlled, operated, and actively managed by a person or persons with visible / non-visible physical and/or mental disabilities.

Other (please describe)

N/A - None of the above

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* 11. If your company falls into any of the categories above, is your company certified by a third-party certifying organization?

Yes - National LGBT Chamber of Commerce Certification

Yes - National Minority Supplier Development Council

Yes - National Veteran Business Development Council

Yes - Women's Business Enterprise National Council

Yes - Other (please specify)