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Vendor Registration

Purchasing Vendor Information Form

Company Information

Business Name (as shown on your tax return)

Doing Business As (if different than above)

Order Address (street, city, zip, state)

Remit Address (if different than above)

Contact Name

Phone

Email

Ownership Status
Please complete the following ownership status (must be completed before a vendor can be set up).

Historically Underutilized Business

Minority Women Business Enterprise (MWBE)

  • If MBE, please choose:

    • African American

    • American Indian

    • Asian American

    • Latino

  • If WBE, please choose:

    • Women Business Enterprise

  • If DBE, please choose:

    • Disabled Business

    • Disadvantaged Business

Not Applicable

Certifying Agency
Please check the certifying agency (please send a copy of current certification letter, if applicable).

NC Office for Historically Underutilized Business (HUB Office)

NC Department of Transportation (NCDOT)

Self-certified (no current 3rd party certification)

Interested in 3rd party certification with the NC HUB Office

Interested in 3rd party certification with the NCDOT

Not Applicable

Products and/or Services
Please enter any products/services with which you would like your company to be identified.

I hereby certify that the information provided herein is correct:


Name & title


Date



Security Measure