DATE 04-23-2014

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Company Name:
Physical Address:
Address (continue):
City:
State/Zip: / 
Mailing Address:
Address Line2:
City:
State/Zip: / 
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)


NameTitleGenderGLBTEthnicityCitizenship% Ownership

Contact Name:
Contact Title:
Phone Number:(Ex.XXX-XXX-XXXX) Ext. 
Fax Number:(Ex.XXX-XXX-XXXX)
E-mail Address:
Business Type:
Legal Structure:
Geographical Service Area:
Year Business was Established:
Number of Employees:
Are you Electronic Data Interchange (EDI) capable?   EDI Version: 
Certificate of Insurance:
CTRL-click to select multiple insurances.
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.
2013:
2012:
2011:

ALL ABOUT YOU - REFERENCES

Major customers you do business with:

Company NameContact NameAddressPhone Number(XXX-XXX-XXXX)
Address(Cont.):  
City:  
State/Zip:   / 
Address(Cont.):  
City:  
State/Zip:   / 
Address(Cont.):  
City:  
State/Zip:   / 

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
Certification No.
Expiration Date (MM-DD-YYYY)
Other agencies that have certified you and your business:
Certifying Agency(2)
Certification Type
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.