Vendor Questionnaire

Only requires completion by MBE, WBE, PDBE, or VOSOB Vendors

Company Name

Company Address

Contact Name + Title

Phone

(###)

###

####

Commodity

Type of Ownership:

Proprietorship

Partnership

Corporation

Other

Number of Years in Business

DBE Information

Classification of Disadvantaged Business Enterprise (DBE) An MBE/WBE/PDBE/VOSB is a business enterprise that meets one of the below requirements: (Please check the appropriate box)

Minority - Owned Business Enterprise (MBE)

Minority-Owned Business Enterprise (MBE) – A business that is at least 51 percent owned by one or more minorities. A person who is a U.S. citizen or lawful permanent resident and is African American, Hispanic American, Asian American, Native American, as well as other groups found to be disadvantaged pursuant to Section 8 (a) of the Small Business Act.

Women-Owned Business Enterprise (WBE)

Women-Owned Business Enterprise (WBE) - A business that is at least 51 percent owned by a woman or women who are United States Citizens or lawful permanent residents of the United States.

Persons with Disabilities-Owned Business Enterprise (PDBE)

Persons with Disabilities-Owned Business Enterprise (PDBE) - A business that is at least 51 percent owned by a person or group of persons with a disability, as recognized by the Americans with Disabilities Act, or as defined by the Commonwealth of Pennsylvania, Governor’s Office, Management Directive 205.25 Amended.

Veteran-Owned Small Business (VOSB)

Veteran-Owned Small Business (VOSB) - A business that is at least 51 percent owned by one or more veterans who are United States Citizens or lawful permanent residents of the United States.

Certifications:

List agencies, institutions or major corporations which have certified your firm as a MBE/ WBE/PDBE/VOSB (e.g. Regional Minority Purchasing Council, City of Philadelphia, PA Dept. of Transportation, etc.)

Agency/Institution

Contact Person

Phone

(###)

###

####

Fax

Approval Date

Agency/Institution

Contact Person

Phone

(###)

###

####

Fax

Approval Date

Authorization

I hereby certify that the information supplied in this form is complete and correct to the best of my knowledge and belief. I authorize Orange Recycling Services, Inc. to verify any of this information as needed.

Name

Title

Date

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