Prospective Supplier Registration

*Indicates required field

Company Details
* Company Name:
* Tax ID/Registration Number:
* Company's Website Address (URL):
* Street Address:
  P.O. Box:
  Suite/Floor Number:
  Additional Address Line (if needed):
* City/Town/Locality:
* State/Region:
  Province (if applicable):
* Postal/Zip Code:
  CenturyLink Point of Contact(s) (if known):

Contact Information
*  First Name:
*  Last Name:
*  Email:
*  Phone number including area code – country code if international:
   Phone Extension (if applicable):

About Your Company

*  List your SIC/ NAICS code(s), up to 8 codes:

*  Tell us what Products and/or Services your company offers:
Category 1:
Category 2:
Category 3:

If a provider of IT Hardware, identify OEM and Software Publisher products you are authorized to sell (i.e., Microsoft Select Program):
Character limit: 300.

If a supplier of IT Software, identify the applications you are authorized by the Software Publisher to support:

Brief description of any other Products or Services offered:
Character limit: 500.

*  How many years has your company been in business?
Less than 1 years
1 - 5 years
5 - 10 years
10 - 20 years
20+ years

*  Have you conducted business with CenturyLink or one of its subsidiaries in the past?

        If yes, when?

Provide the name of the CenturyLink contact you worked with in the past (if applicable):

*  Last (2) year's sales revenues (numerical input only):

*  Next year's projected sales revenue (numerical input only):

What Business, partnerships or certifications do you have?
Character limit: 100.

*  Number of business customers currently purchasing products/services from your company (numerical input only):

*  Who are your top 5 business customers?
Character limit: 100.

*  What states do you currently operate in?

*  Are you a manufacturer?

        If yes, what trade names do you sell?
Character limit: 100.

*  Are you a distributor/re-seller?

        If yes, who are the key manufacturers/key suppliers you represent?
Character limit: 100.

Diverse Supplier Information

*  Are you a certified diverse company?

        If yes, please select which classification status for certification:
        (Select up to three.)
SBA 8(a)
HUBZone (SBA certified only)
Small Business
Small Disadvantaged Business (minority owned)
Women Owned Business
Veteran Owned Business
Service Disabled Veteran Owned Business
Gay, Lesbian, Bi-Sexual, Transgender (GLBT)
Alaska Native Corporation (ANC)
Historically Black College/University/Minority Institution
Large Business
US Owner Business
Non US/Foreign Owned Business (additional FOCI documentation will be Required)
ORCA Registration

        If yes, what state and/or certifying agency have granted the above diverse classification?

*  Does your company track and report 2nd tier diversity spend?

If you are a Diverse Supplier, please provide a copy of your certification to the following email address: Supplier.Diversity@Centurylink.com

If you have any questions about this survey, please contact Survey Requests.