Supplier Registration Form

For consideration on future bid opportunities, please complete our Supplier Registration form below.

Contact Information:
Company Name:


Address:


City:


State:


Zip:


Contact Name:


Contact Title:


Email:


Phone:


Fax:


Website:


Diversity Certification (If applicable):
Please indicate if your company is at least 51% owned by a member of the following groups:
	Women	Asian	Black	Hispanic
Select all that apply:




	Disabled	Native American	Veteran	Service Disabled Veteran
(continued)




Select all certifications held by your company:
	MBE	WBE	SBE	Other
Select all that apply:




If 'Other', please specify:


Company Information:
(EIN#) Employer Identification:


Year Founded:


Legal Structure:

If 'Other', please specify:


Annual Revenue:

Products & Services Provided:

If 'Other' selected above, please describe:


Number of Full Time Employees:


Please list at least one primary customer and include any customers similar in size and shape to GfK:
Primary Customer 1:


Primary Customer 2:


Primary Customer 3:



Referal Source:	How did you learn about our program?

Are you currently doing business with GfK?	Yes
	No

Additional Information:	Please use this space to provide additional information on your company, (e.g. Awards, Recognition, Patents, Innovations, Community Involvement etc.)

By submitting this form, I hereby state that the above information given is complete and correct, and that no false or misleading information or false statements have been given.
Please enter the text in the image in the field below!



GfK Custom Research North America does not sell or share information received with entities outside of GfK who may want to market to you their own products and services. For more information, please see our privacy policy.
Or if you prefer, contact us at GfK Custom Research North America, 75 Ninth Avenue, 5th Floor, New York, NY 10011 * T 212.240.5300 * F 212.240.5353 * info@gfkamerica.com

Supplier Registration Form

Contact Information:

Diversity Certification (If applicable):

Company Information: