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?* Manufacturer Distributor Not 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

(Check all that apply.)

African American	Hispanic American
Native American	Asian Pacific American
Asian Indian American	Other:
Alaskan Native Corporation or Alaskan Indian Tribe

(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*

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 CoastMidwest West CoastMid-Continent NortheastRocky Mountain SoutheastInternational

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