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National Grid Use Only
Supplier ID#: _________________________
Approved By: ________________________
Approval Date: _______________________
Approved Supplier
FSS:
Enrollment Form
Legal Co. Name _____________________________________________________________________________
Supplier Address: _____________________________
Remit-To: _______________________________
______________________________
_______________________________
______________________________
_______________________________
______________________________
_______________________________
Contact Name: ________________________________
Title: ________________________________
Phone Number: ________________________
Ext. ________
Fax Number: __________________________
Email Address: ____________________________________________
ACH Payment: ___Yes or ___No *(Required ACH Form to be attached)
SIC Code(s): ______________________________________________________________________________
UVDB(s): _________________________________________________________________________________
DUNS #: ___________________________ Accept P-Cards: Yes or No ____________________________
FEDERAL TAX ID #: _____________________________ *(Required W-9 Form to be attached)
NATIONAL GRID SUPPLIER DIVERSITY AND SOCIO-ECONOMIC BUSINESS SOLUTIONS
PLEASE CHECK ALL THAT APPLY
Large Business
Small Disadvantage Business (SDB)
Small Business (SB)
Small Disadvantaged (8a)
Woman Owned Business
Veteran Owned Business
Minority Owned Business
Service Disabled Veteran Owned Business
African American
HUBZone Certified
Alaskan Native/Indian Tribe
Gay Lesbian Bisexual Transgender
Alaskan Native/Indian Tribe not Certified
by SBA as SDB
Historically Black Colleges
Native American
Protected Workshop (Disabled)
Asian Pacific American
Green Certified
Hispanic American
Foreign Business
Subcontinent Asian
If your business is certified in any of the above categories, who certified you
New York State
Greater New England Minority Supplier Development Council
National Minority Supplier Development Council (NMSDC)
Women Business Enterprise National Council (WBENC)
Other (please specify):
Copies of Certifications are required. Please fax or email your certificates to (315) 428-6711 or
PENALTY FOR FALSE MISREPRESENTATION:
Under 15 U.S.C. 645(d), any person who misrepresents a firm’s status shall (1) be punished by a fine, imprisonment, or
both; (2) be subject to administrative remedies and (3) be ineligible for participation in programs conducted under the
authority of the Act.
Authorized Signature ___________________________________
Date ______________________________