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Vendor Registration

^* Field is required.

Please fill out the following company information:

Company:^* Address 1:^* Address 2: City: State: ZIP:^*

CEO or Owner's Name:

First Name:^* Last Name:^* Main Phone Number:^* (###)###-#### Company Fax Number:^* (###)###-#### Order Processing E-mail:^* user@example.com Company Website URL: http://www.example.com

Primary Contact:

First Name:^* Last Name:^* Title:^* Primary Contact Cell Number:^* (###)###-#### Primary Contact E-mail Address^* user@example.com Federal ID Number: Insurance Carrier^*

Is your organization Electronic Data Interchange (EDI) capable or able to accept electronic POs via e-mail?:^* Yes No

Projected Volume for the Current Year:^* Last Year:^* Two Years Ago: Three Years Ago: What is your company's market share percentage in your industry?^* Who are your three largest competitors and their percentage of market share? Who are your top 3 customers, based on total sales volume, for your product mix? (Listed from largest to smallest):

Will you agree to central invoice, consolidating information from POs to multiple ship to locations?:^* Yes No

Are you a minority or women owned business (51% required ownership)?:^* Yes No

Please provide a 250 word or less description of your products or services and how you would foresee being a value: 250 words or less What is the brand name(s) you market your product(s) under?:^*

The YMCA

For Youth Development ^™
For Healthy Living
For Social Responsibility