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-~, <br />Chevron <br />• <br />Supplier Information Formf <br />Supplier Number (Chevron Use Only) <br />Company Name Company Type <br /> ^ Manufacturer ^ Distributor ^ Broker <br /> ^ Manufacturer's Rep ^ Service ^ Other <br />Correspondence Address Remittance Address, If different ham Correspondence Address <br />City. State. Zip Ciry. State, Zip <br />Primary Contact Title Telephone and Fax Nos. <br />When was your company founded? Number of Employees <br />Sales volume for the most recent year 119 _ I S <br />Does your company accept Mastercard? ^ Yes ^ No Federal Tax ID: <br />GEOGRAPHIC SERVICE AREA:1Cucle only anel <br />I -INTERNATIONAL N -NATIONAL R -REGIONAL L -LOLL <br />If regional or local, please spbcify ary or state: <br />BUSINESS CLASSIFIGTION (See definitions on reverse side of this form.l <br />In accordance with Government regulations and prime contract requirements, we are required to verity the business site and classification of our suppliers and potential <br />suppliers THE RESPONSIBILITY OF DETERMINING CLASSIFICATION TYPE FOR YOUR BUSINESS IS YOURS. If you have questions, please contact your U.S. Small Business <br />Administration Office. PLEASE CHECK ALL APPROPRIATE BOXES IN EACH SECTION. <br />ECTION A SECTION R SECTION C: CERTIPIGTION <br />^ t. Large Business Concern Note: We recognize the following groups <br />^ 2. Small Disadvantaged as minorities. Please check rf your business Certified as MBE or WBE? ^ Yes ^ No <br />Business Concern falls into one of these categories. Certified by - <br />^ 3. Small Business Concern ^ Black Amencan IAI <br />^ 4. Women-Owned Business ^ Hispanic Amencan IBI Are you a member of a regional minority purchasing council? ^ Yes ^ No <br />^ 5. O~sabled Veteran Concern ^ Asian-Pacific American 1CI <br />^ Native American 101 If you are a member of a minority purchasing council, indicate council namelsl~ <br />^ Other, as designated by the SRA 1E1 <br />PRINCIPAL OWNERS OF COMPANY 96 <br />Name Title Ownership <br /> <br /> <br /> <br />IMPORTANT: Please refer to the Commodity/Service Codes Usting attached and identAy the primary commodity and/or <br />service your company offers (maximum of three categoriesl. Please designate corresponding code number <br />in each box. <br />1. <br />2. <br />3. <br /> <br />GO.15Z5I6-94 <br />R~xed'n LLi~ <br />vyraa <br />