Supplier Registration Form

Thank you for your interest in registering with Apex Computer Systems, Inc. Once registered, your supplier profile will be in our database and will be evaluated should business opportunities arise for the products or services your company provides.

Business Information (* Indicates required fields)

• Company Name *
• Owner Name
• Company Address *
• City, State, Zip Code *
• Federal ID or SSN *
• Tax ID *
• Dun Bradstreet ID
• Tax Jurisdiction
• Tax Exempt
  Yes No
• Contact Name *
• Job Title *
• Phone Number *
  - - Ext
• Email Address *
• Company website *
• Company Ownership *
  Privately Owned Publicly Traded

Business Profile

• Date Established *
• Number of Employees *
• Legal Structure *
  • Sole Proprietorship Corporation
  • Limited Liability Company Partnership
  • Other
• Business Type *
  • Manufacturer Service Provider
  • Distributor Retail
  • Staffing Other
• Geographic Service Capability (Check all that apply) *
  • Local (within city/state) National (USA)
  • Regional (within 3-5 state area) International
• Has your company previously done business with Apex?
  Yes; when? No
• Description of Products or Services *
• Statement of Business Capability
• Annual Sales ($) Amount for last year

  Year	Amount
  Last Year Annual Sales

Diversity Classification & Certification Information

• Diversity-Owned Business *
  Yes No
• Diversity Specification (If yes to previous question) *
  • Minority-Owned Disabled-Owned
  • Veteran-Owned Women-Owned
  • Other
  • Is your business currently certified as a Minority and Women Business Enterprise (MWBE) with National Minority Supplier Development Council (NMSDC), Women's Business Enterprise National Council (WBENC), or associated organizations? If so, please list and attach the certifications to this form.

• 	(1)	(2)	(3)
  Council/Organization
  Certification Number
  Certification Expiration Date

Principal Customer References & Contacts

The undersigned certifies that the information provided above is legitimate and accurately reflects the condition of the company to be registered. The undersigned also understands that any fabrication or attempts to misrepresent the company may result in the loss of its privilege to conduct business with Apex Computer Systems, Inc. and its partners.

• Name
• Date