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  • Instructions: Please provide the following information. If a question does not apply to your company, please indicate "Not Applicable" (n/a) in the blank.

    This information should be updated annually.

        

    Supplier Profile

    Company Name:
    Federal ID #:
    Current DBA (if applicable):
    Phone:
    Fax:
     
    Company Address -
    Street Address:
    City:
    State:
    Zip:
     
    Main Contact Person -
    Name:
    Title:
    Phone:
    Email Address:
       
    Federal Tax ID:
    D&B DUNS Number:
    Average Annual Revenue:
    Principal Officer's Name:
    Principal Officer's Title:
    Principal Officer's Phone:
    Company Website Address:
    Type of Organization:
                               
    Number of Employees:
    NAICS Code:
    Start Date of Business:
    Can your firm accept EDI?
                               
       
    Billing address if different from above -  
    Street Address:
    City:
    State:
    Zip:
       

    Products/Services

    Are you a distributor or manufacturer?     
                              
    Do you offer a product, service or both?
     
    Company category:
     
    Please list all of the products and/or services your firm would like to sell to Windstream:
    Please tell us what states you do business in:
    Are you currently doing business with Windstream?
                             
    What is your Windstream contact's name?
    What is your Windstream contact's phone number?
       

    Sub Contracting: Tier II Diversity Plan

    Does supplier use diverse companies (as listed below) to service or supply Windstream Communications
                             
    Does supplier have a Diversity plan in place?
                             
    Sub contracting diversity plan reporting: (fill in all applicable categories)
    • Minority: %
    • Women Owned: %
    • Veteran Owned: %
    • Disabled Veteran: %
    • Small Business: %
       

    Business Classification

    If your business is classified in one of the areas below, please check all that apply. For further clarification on small, minority or diverse business classifications, please see the SBA website: http://www.sba.gov/training/certprograms.html.

                          
     
    Are you currently certified as an MBE, MWBE, or a DVBE?
                         
       

    CERTIFICATION IS REQUIRED. To be classified as a minority, SDB, HUBZone or 8(a) business your firm must have certification of your status and be a minimum of 51% owned, operated and controlled by oweners that are classified as diverse. In publicly held business, diverse owned members must own at least 51% of stock. Your firm may obtain certification directly through the Small Business Administration, or through other certifying agencies. Please attach a copy of your current certificate with this Profile to support the classification.

    SELF-CERTIFICATION ACCEPTED. To be classified as a Veteran, Service Disabled Veteran, Woman-Owned and/or Small Business, your firm may self-certify by checking this status and signing below. By signing you are stating in writing that your organization is at least 51% owned and operated by the classification indicated and that you are a small business as defined by the U.S. Small Business Administration. Note: Windstream favors certification in most instances.

                         
    *State Agency (if checked above):