Company Name:

Address:

City:

State: Please Select AK AL AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY DC

Zip Code:

Phone:

Toll Free Phone Number:

Fax:

Email:

Website:

Contact Name:

Title:

Phone:

Fax:

Email:

Business Type: Please Select Contractor Distributor Equipment Provider Manufacturer Service Provider Transportation/Logistics Other

NAICS Code:

Federal Tax ID:

Tax Type: Please Select EIN SSN

Year Established:

Year Incorporated:

# of Employees:

Warehouse Space (sq. ft):

Geographic Service Area: Please Select National Regional Local

Annual Sales (last yr):

Annual Sales (2 yrs ago):

Annual Sales (3 yrs ago):

Business Description: Please Provide a brief description of the products/services your company provides.

Current Kroger Supplier? Yes No

If a current Kroger supplier, enter your vendor #:

Company:

Contact Person:

Contact Telephone:

Company:

Contact Person:

Contact Telephone:

Company:

Contact Person:

Contact Telephone:

To be considered for Kroger’s Supplier Diversity Program, we require current certification of minority or woman ownership status. We accept certification from the National Minority Supplier Diversity Council (NMSDC) and it’s regional affiliates, the Women’s Business Enterprise National Council (WBENC) and it’s regional affiliates, or the appropriate Local, State or Federal agency.

M/WBE Certifying Agency: Please Select NMSDC or Regional Affiliate WBENC or Regional Affiliate SBA/Federal State Local

If current, enter expiration date (mm/dd/yyyy):

If pending, enter date applied (mm/dd/yyyy):

Preparer's Initials:

Preparer's Name:

Preparer's Title:

Preparer's Phone Number:

Preparer's Email Address:

Date: