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Supplier Diversity Program

Supplier Diversity Registration Form

Please complete the form below to be considered for Ricoh’s Supplier Diversity Program.

* indicates required field

Company name* Company name
DBA Name DBA Name
Tax ID Number* Tax ID Number
Address Address Line 1
 Address Line 2
Address * City City
State State
Zip Code
(Example: 00000) 		Zip Code
Phone*
(Example: 000-000-0000) 		Phone
 Fax
Contact Name * Contact Name
E-mail Address*
(Example: xxxxxx@xxxxxx.xxx) 		E-mail address
D&B DUNS Number D&B DUNS Number
Cage Code Cage Code
NAICS Code* Primary NAICS Code
 Secondary NAICS Code
Registered with Small Business Administration?*
Diversity Classifications Select all Diversity
Classifications that apply







Type of Business* Select Type of Business
 If Other, please describe:
Legal Structure* Select Legal Structure
Company Profile Service Area Select Service Area
Your company’s products/services Please provide brief description of your Company’s products/services (200 words or less)
Do you have an online catalog? Do you have an online catalog?
E-Business* Can you sell your products/services online? Can you sell your products/services online?
Electronic Data Interchange (EDI) Capable? Are you Electronic Data Interchange (EDI) Capable?
Certified with Diversity Agency?* Certified with Diversity Agency?
National Minority Supplier Development Council (NMSDC) Certification Number
 Start Date (mm/dd/yyyy)
 End Date (mm/dd/yyyy)
Small Business Administration (SBA) Certification Number
 Start Date (mm/dd/yyyy)
 End Date (mm/dd/yyyy)
Diversity Certifications Disadvantaged Business Enterprise (DBE) Certification Number
 Start Date (mm/dd/yyyy)
 End Date (mm/dd/yyyy)
Women’s Business Enterprise National Council (WBENC) Certification Number
 Start Date (mm/dd/yyyy)
 End Date (mm/dd/yyyy)
Small Disadvantage Business (SDB) Certification Number
 Start Date (mm/dd/yyyy)
 End Date (mm/dd/yyyy)
Historically Underutilized Business (HUB) Certification Number
 Start Date (mm/dd/yyyy)
 End Date (mm/dd/yyyy)
Other
(Please identify) 		Organization
 Certification Number
Start Date (mm/dd/yyyy)
 End Date (mm/dd/yyyy)
Attachment Please attach only one file.(you may zip multiple files. Attach pdf,docx,doc,txt,zip file types only. 3MB Max)
Security Code* security code
Please enter code exactly as shown in image format. Please enter code exactly as shown in image format

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