Supplier Diversity Self-Certification Form.

The following information is being requested on behalf of Crowley Webb/Praxis in support of our Supplier Diversity Program.  Our Supplier Diversity Program is designed to increase the inclusion of diverse businesses in our sourcing process and report when necessary to our clients and vendors.

We kindly request you complete the following form and submit a certification of company status as a diverse business enterprise if applicable.

Supplier Diversity

*Indicates required field

Instagram

This field is for validation purposes and should be left unchanged.

Company name*

Name of individual affirming certification*

First Last

Title of individual affirming certification

Phone

Email

If applicable, please attach a copy of your certification for our records

Max. file size: 512 MB.

Diversity status

Please select all that apply.

Minority-Owned Business Enterprise

Woman-Owned Business Enterprise

LGBTQ-Owned

Disabled-Owned Business

Service Disabled Veteran-Owned Business

Veteran-Owned Business

HUBZONE Business

Small Business Enterprise

Women-Owned Small Business

8a-Certified

Other Diverse

Not applicable to Company

If other, please add status*

Signature of individual affirming certification*

Date*

MM slash DD slash YYYY

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