DATE	05-16-2012

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Company Name:
Physical Address:
Address (continue):
City:
State/Zip:	Select One... ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DIST 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 PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING  /
	Mailing Address is the same with Physical Address.
Mailing Address:
Address Line2:
City:
State/Zip:	Select One... ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DIST 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 PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING  /
Company Phone Number:(Ex.XXX-XXX-XXXX)	Ext.
Company Fax Number:(Ex.XXX-XXX-XXXX)
Principle E-Mail Address:
Company Website (URL):

ALL ABOUT YOU - COMPANY PRINCIPAL (MAJORITY OWNER INFORMATION)

Name	Title	Gender	GLBT	Ethnicity	Citizenship	% Ownership
		Male Female	Select One Gay Lesbian Bisexual Transgender	Select One African American Asian American Hispanic American Native American Other	U.S. Citizen Non U.S. Citizen

Contact Name:
Contact Title:
Phone Number:(Ex.XXX-XXX-XXXX)	Ext.
Fax Number:(Ex.XXX-XXX-XXXX)
E-mail Address:
Business Type:	Select One Logistics & Store Support Print & Paper Store Environment & Fixtures Building Equiptment & Services Business Services Information Technology Retail-Women's Retail-Men's Retail-Children Retail-Home Other
Legal Structure:	Select One Corporation Joint Venture Limited Liability Corporation Limited Liability Partnership Partnership Sole Proprietorship Other
Geographical Service Area:	Select One International Local National Regional
Year Business was Established:
Number of Employees:
Are you Electronic Data Interchange (EDI) capable?	Select One Yes No    EDI Version:
Certificate of Insurance: CTRL-click to select multiple insurances.	Automobile Liability Commercial General Liability Employer's Liability Employment Practices Liability Errors and Omissions Worker's Compensation
Insurance Carrier:
DUN and Bradstreet Number:
Primary SIC Code(s):

ALL ABOUT YOU - PRODUCTS AND/OR SERVICES

Enter your business description. (up to 500 characters)

ALL ABOUT YOU - ANNUAL SALES VOLUME - PAST 3 YEARS REQUIRED

Please round Sales to the nearest whole dollar.
2011:	$
2010:	$
2009:	$

ALL ABOUT YOU - REFERENCES

Major customers you do business with:

Company Name	Contact Name	Address	Phone Number(XXX-XXX-XXXX)
	Address(Cont.):
	City:
	State/Zip:	Select One... ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DIST 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 PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING  /
	Address(Cont.):
	City:
	State/Zip:	Select One... ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DIST 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 PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING  /
	Address(Cont.):
	City:
	State/Zip:	Select One... ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DIST 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 PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING  /

ALL ABOUT YOU - CERTIFICATION

Please provide information regarding your certification and fax a copy of your certificate to JCPenney Supplier Diversity at 972-531-6260

Certifying Agency(1)
Certification Type		Select One NGLCC NMSDC WBENC DOT GRANT RECIPIENT OTHER
Certification No.
Expiration Date		(MM-DD-YYYY)
Other agencies that have certified you and your business:
Certifying Agency(2)
Certification Type	Select One NGLCC NMSDC WBENC DOT GRANT RECIPIENT OTHER
Certification No.
Expiration Date	(MM-DD-YYYY)

Please do not send samples as they will NOT be returned.

Additional Information such as brochures, photos of your product, financial statements and credit references may be requested if needed or in the case that your commodity/services becomes available for bid.

By choosing to SUBMIT this form, you certify that the information you have provided above is true and accurate.