Supplier Information
Potential Supplier Application

Suppliers interested in doing business with LexisNexis should complete the Potential Supplier Application.

* Indicates a required field
 

Company Information
*Company Name
*Address 1
Address 2
*City
*State/Province *Zip
*Country
*Phone
*Fax  
*Contact  
*Email
*Contact Title  
Web Site

 

Business Ownership

Is the business owner a U.S. Citizen or Legal Resident Alien?
Yes     No
If No, please explain:  
 
Business Size
Large     Small

 

Business Structure
Incorporated
Publicly Held  Privately Held  Partnership 
Incorporated State  Other   
Parent Company
Duns Code
 
Business Ownership Ethnicity
African-American  Asian-Indian  Asian-Pacific 
Hispanic  Native-American  Other 
If Other, please explain:  

*Business Classification (check all that apply)
Minority-Owned Business    Women-Owned Business 
Veteran-Owned Business    HUBzone 
Disabled Veteran-Owned Business    Other 
Percent Ownership % 

 

Certification
Has your company been certified by any regional NMSDC Purchasing council?
Yes     No
  
Has your company been certified by the Small Business Administration?
Yes     No
  
Has your firm been classified as a minority, women or disadvantaged business enterprise by other agencies?
Yes     No 
If Yes, what agency?

 

*Principle Product or Services (check all that apply)

Audio Visual  Communication  Copier 
Computers  Electrical  Facilities 
Freight  Mail Center  Marketing 
Outsource  Office Supplies  Paper 
Packaging  Photo Equipment  Promotional 
Services  Software  Telecommunications 
Other 
If Other, please specify:  

 
Certification

Please have certification documents available upon request.
 
LexisNexis standard payment terms are net 45.

On behalf of the company identified herein, the undersigned certifies all information listed on this form to be correct and true by pressing the Submit button.
 
 *Name  *Title Date 11/21/2008