Supplier Registration Form

Supplier Registration

Please complete the form below to register your company.

Supplier Data

Legal Company Name	Do you have a pending/past-due invoice? (Check if true)
DBA/Trade Name	BCBSA Contact Email
DUNS Number
Company Structure

Corporate Headquarters-US

Country		Street
City		State
Zip code
Phone		Fax
Website

Contact Information

Primary Contact
First Name		Last Name
Title		Same as Corporate Address
Address		City
State
Zip code		Zip +4
Work Phone		Cell Phone
Fax		Email

Secondary Contact
First Name		Last Name
Title		Same as Corporate Address
Address		City
State
Zip code		Zip +4
Work Phone		Cell Phone
Fax		Email

Company Description

Product/Services Provided		Business Strengths / Differentiators
Current Geographical Area Serviced		Choose your regional locations

Total number of current employees		NAICS Codes (separate by comma)
Main Industry Category		Sub Industry Category

Are you a diverse supplier? (Check if true)
Are you a small or large business?	(Please click here to verify if your quality as a small business as per SBA)

IMPORTANT NOTICE

Make sure to review definitions for diverse business certifications in Federal Acquisition Regulation 19.7 or 52 219-8 at https://www.acquisitior.gov/far before responding below. For questions, check the US Small Business Administration's website at https://www.sba.gov/ or contact your local SBA office.

Diversity Information

Are you SAM (CCR) listed? (Check if true)		What is your CAGE Code?
Have you submitted/completed your FAR and DFARS provisions? (Check if true)		Expiration Date

Diverse Classification	Certified By	Agency Name	Other Agency Name	Expiration Date
Minority Business Enterprise (MBE)
Woman Owned Business Enterprise (WBE)
Veteran owned Business Enterprise (VET)
Service Disabled Veteran Owned Business Enterprise (SDV)
Lesbian / Gay / Bisexual / Transgender Owned Business Enterprise (LGBT)
Hubzone (HUBZ)
Small Disadvantaged Business Enterprise (SDB)
Small Business Enterprise (SBE)
Disadvantaged Business Enterprise (DBE)
Disabled Person Owned Business Enterprise (DOBE)
Small Business Administration 8(a) (SBA 8(a))
Woman-Owned Small Business (WOSB)
Economically Disadvantaged Woman-Owned Small Business (EDWOSB)
Historically Black College/University or Minority Institution (HBCU)
Alaskan Native and Indian Tribe (ANIT)
Other (OTHER)

Click to confirm Supplier’s understanding

I AGREE Information provided above is for informational purposes only. This submission does not bind or impose any legal obligation upon BCBSA or Supplier, does not imply that BCBSA and Supplier will enter into any resulting contract or sales, and does not limit BCBSA’s right to operate in BCBSA’s best interest with any other suppliers.

I AGREE All information is complete and accurate, as provided above. Misrepresentation of any facts above (including but not limited minority ownership, diversity, or small business status) will jeopardize Supplier’s ability to do business with BCBSA and may also be punishable by fines, imprisonment, and other penalties under Federal and State laws.

I AGREE The undersigned has full authority to provide the information above on behalf of Supplier.

I AGREE BCBSA provides this portal for the convenience of its business partners. In electing to use this portal, you assume all responsibility arising out of your registration for and use of this portal, including with respect to the access provided to users whom you authorize to use the portal, and the accuracy of the information that you or anyone you authorize or have previously authorized to use the portal on your behalf provides. It is a condition of registration that you release BCBSA for all claims, loss or damage resulting from actions by you or your current or former employees, contractors, agents or any others whom you authorize or previously authorized to use the portal.

Printed Name	Authorized Representative	Title
Signature	Retype Printed Name for Signature	Date