Supplier Information Request Form
To complete the form, please fill in all the fields marked with an asterisk (*) and an 'I' icon. These fields are mandatory and cannot be left blank. The 'I' icon provides you with more details about the purpose and format of each field. You can hover over the icon to see the information. Thank you for your cooperation.

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* Indicates required field
*Legal Company Name :
*Main Phone Number :	(999-999-9999)    Ext:
*Street Address or PO Box:
*City:
*State/Province:	Select State ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING ALBERTA BRITISH COLUMBIA MANITOBA NEW BRUNSWICK NEWFOUNDLAND AND LABRADOR NOVA SCOTIA ONTARIO PRINCE EDWARD ISLAND QUEBEC SASKATCHEWAN
*Zip:
*Federal Tax ID Number:
Business Owner/Requester or Sponsor :
Small Business:  Yes  No Woman-Owned Business:  Yes  No Currently Certified MBE, MWBE, or DVBE:  Yes  No Minority-Owned Business:  Yes  No Second Tier Minority:  Yes  No Veteran-Owned Business:  Yes  No
Please Note: Windstream values diversity and inclusion among its suppliers. If your company qualifies as a Minority, Women, Disabled, Veteran, or Business Enterprise (M/W/DV/BE) under any of the classifications we recognize, please register with Supplier.io. They may ask you to provide certification from certain agencies to verify your status.
*Master Agreement with Windstream  : Yes  No *Non Disclosure Agreement:  (Is Required)  Yes  No
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