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Supplier Diversity Program Vendor Profile

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NEW YORK POWER AUTHORITY SUPPLIER DIVERSITY PROGRAM 

VENDOR PROFILE
(en español)

1. TYPE OF RESPONSE
____Initial
____Revision
2. DATE

NOTE: Complete all items on this form. Insert N/A in items not applicable. Please include company literature or brochure with this form.

3. NAME AND ADDRESS OF NYPA ENTITY TO WHICH FORM SUBMITTED
New York Power Authority
123 Main Street
White Plains, NY 10601-3104
Attention: Contract Administration Division, SDP
4. NAME AND ADDRESS OF APPLICANT (include country and nine-digit ZIP+4)
5. TYPE OF ORGANIZATION (CHECK ONE):
_______ Individual
_______ Partnership
_______ Non-Profit
_______ Corporation (Incorporated under the laws of the State of __________)
6. ADDRESS TO WHICH SOLICITATIONS ARE TO BE MAILED (if different than Item 4)

7. NAMES OF OFFICERS, OWNERS OR PARTNERS

A. PRESIDENT
B. VICE PRESIDENT
C. SECRETARY
D. TREASURER
E. OWNERS OR PARTNERS
8. AFFILIATES OF APPLICANT (Names, locations, nature of affiliation, etc.)
9. IDENTIFY EQUIPMENT, SUPPLIES, AND/OR SERVICES ON WHICH YOU DESIRE TO MAKE AN OFFER
(Provide SIC Codes, if available)
10. SIZE OF BUSINESS
_______ Small Business
_______ Other than Small Business
11. AVERAGE NUMBER OF EMPLOYEES (including affiliates) FOR FOUR PRECEDING QUARTERS (Add "/P" if for Parent Company)
________ AS OF _____/_____/_____
MO/DAY/YR
12. AVERAGE SALES OR RECEIPTS FOR PRECEDING THREE FISCAL YEARS (Add "/P" if for Parent Company)

$________________AS OF _____/_____/_____
MO/DAY/YR
13. TYPE OF OWNERSHIP (See definitions in NYPA Guide)
________ Minority Business Enterprise
________ Women-Owned Business Enterprise
NYS M/WBE Certification No.
__________________________
14. TYPE OF BUSINESS
________ Manufacturer/Producer
________ Manufacturing Representative
________ Service Establishment
________ Consultant (Personal Services)
________ Regular Dealer
________ Surplus Dealer
________ Construction Concern
15. DUNS NO. (If available)
16. YEAR BUSINESS FORMED? (Add "/P" if year Parent Company formed)
17. PAYEE IDENTIFICATION NUMBERS
A. FEDERAL SOCIAL SECURITY ACCOUNT NUMBER: _______________
B. FEDERAL EMPLOYER ID NUMBER: _____________________________
18. COLLECTIVE BARGAINING AGREEMENTS (List of locals and Trades, if any, with contract expiration dates)

19. LICENSING AGREEMENTS (List any licensing agreements required to provide your product/service, exp. Dates, and whether your business is licensee or licensor)
20. BONDING REFERENCE (List highest bond received, date and bonding reference)
CERTIFICATION: I certify that information supplied herein (including all pages attached) is correct and that neither the applicant nor any person (or concern) in any connection with the applicant as a principal or officer, so far as is known, is now debarred or otherwise declared ineligible by any agency of the State of New York from making offers for furnishing materials, supplies, or services to the State of New York or any agency thereof.
21. Name/Title of Person Authorized to sign (Type or Print)


22. SIGNATURE 23. DATE