SUPPLIER DIVERSITY REGISTRATION Supplier Profile Fields marked with an * are required. Company Information Company Name:* Company Type:* Select One Advertising Apparel Benefits Chemicals Construction Consultant Contractor Cooking Ingredients Finance Hardware/Software HR/Personnel Service Information Technology Insurance Janitorial Services MRO/Industrial Services Office Supplies Packaging Printers Promotional Products Safety Service Telecommunications Training Transportation Travel & Events Utilities Other Which of the following best describes your company?* ManufacturerDistributorNot Applicable Street Address:* City:* State:* Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Postal Code:* Telephone Number:* Fax Number:* E-mail Address:* Web Site Address: Contact Name:* Federal Tax ID #: Example: 12-1234567 Dun & Bradstreet #: Example: 12-123-1234 Business Ownership (Check all that apply.) African American Hispanic American Native American Asian Pacific American Asian Indian American Other: Alaskan Native Corporation or Alaskan Indian Tribe Business Classification (Check all that apply.) Large Business Concern Veteran Small Business Concern Disabled Veteran Woman-Owned Disadvantaged Veteran Disabled-Owned Vietnam Veteran Minority Business Concern 8(A) Designation Hub Zone LGBTQ Other: List of Products and/or Services* Additional Company Information Standard Industry Code(s) (SIC):* Is your company EDI ready?* YesNo Is your company credit card (payment) ready?* YesNo Has your business been certified by a third party organization?* YesNo If so, which organization? (Check all that apply.) National Minority Supplier Development Council (NMSDC) or its affiliate Certification No.: Exp. Date (MM/DD/YYYY): Women's Business Enterprise National Council (WBENC) or its affiliate Certification No.: Exp. Date (MM/DD/YYYY): Small Business Administration or its approved certification organization Certification No.: Exp. Date (MM/DD/YYYY): State Government Certification No.: Exp. Date (MM/DD/YYYY): Municipal Government Certification No.: Exp. Date (MM/DD/YYYY): Local Purchasing Councils Certification No.: Exp. Date (MM/DD/YYYY): Self Certification Certification No.: Exp. Date (MM/DD/YYYY): Other: When contract mandates, can your company provide the following safety and insurance information? Does your company have a safety program?* YesNo OSHA Total Recordable Rate (TRR)for safety incidents for the past three years?* YesNo Workers Compensation Experience Modification Rate (EMR) for the past three years?* YesNo Commercial general and automobile liability insurance with limits of 2mm or greater?* YesNo Where did you learn about Tyson Foods, Inc. Supplier Diversity Program? (Check all that apply.) Expo Women Council Minority Council Other: Please identify the geographical area served (Check all that apply.) Gulf CoastMidwestWest CoastMid-ContinentNortheastRocky MountainSoutheastInternational Annual Sales (past 3 years):* $ Year 1 (most recent complete fiscal year) $ Year 2 $ Year 3 Number of Employees:* Number of Minority Employees:* Year Company Established:* Major Customers:* Customer Name Contact Name Phone Number Are you an existing Tyson Foods, Inc. Supplier?* YesNo If yes, please indicate which business units or organization of Tyson Foods you have conducted business with in the last 24 months. Also list the product/service Business Unit/Organization Product/Service Buyer/Contact Name