Fax Cover Sheet

The following information is required by your customer / client, Puget Sound Energy, and is being requested by
CVM Solutions, LLC, on their behalf. Puget Sound Energy is required to maintain verification of diversity
status from all suppliers that are part of its Supplier Diversity Program. This information is critical to ensuring
the accuracy of the Program’s diversity reporting.

Our records show that your company is a diverse business. Our records also show that we do not have a current
copy of your diversity ownership certificate, or self-certification form on file. In order to verify that the
information we have on file is accurate, we request that you complete and return this form, along with any
diversity certificates by email to: PugetSound@CVMSolutions.com or fax to (630) 818-2804.

Bill Milarski
630-925-4243

Professional Services and Vendor Profile

 Instructions:
• Suppliers, contractors and providers complete all sections, sign, date
and return
• Non-Suppliers (employees, partners, etc.) please check the “non-
supplier box” and return Non-Supplier
Legal Company       NAICS Code or SIC      
Name = Code
DBA/AKA Name       Fed Tax ID or      
SSN (if Individual)
Current Address       D&B Number      
City       State       Zip code       Phone Number      
Remit To Address       Fax Number      
City       State       Zip code       Web Site      
Business Owner Name Email Address      
Business Owner Email Address # of Employees      
Annual Sales      
Business Classification
Minority Business Enterprise (MBE) Ethnicity:
Women Business Enterprise (WBE) African American Asian
Small Disadvantaged Business (SDB) Hispanic American Native American
8(a) Certified Business Asian Pacific American
Veteran Owned Business SBA Certification # ____________________________
Service Disabled Veteran Owned Business Other Certifications ____________________________
Historically Underutilized Business (HUB Zones) Other Certifications ____________________________
Lesbian, Gay, Bisexual, Transgender owned Business (LGBTBE)
Gender 

Male Female
Business Size Definition: A small business is a business that is classified as “small” under the guidelines set forth
Small Large by the Small Business Administration. Business size is dependent on the NAICS code, the number of
employees, and the annual sales of a given company. Please refer to www.sba.gov/size for more
details.
Certification As a Small, Ethnic or Woman Owned Enterprise
If applicable, indicate the agency from which your company has been certified as an ethnic or woman owned enterprise, or as a small business
enterprise, and attach a copy of your certification. COPY OF CERTIFICATION REQUIRED.
Certification Expiration Date Certificate Number
Small Business Administration            
NMSDC Affiliated Council            
Women’s Business Enterprise Nat’l Council            
Small Business Administration            
Other:                  
Other:                  
The undersigned declares the foregoing statements are true and correct.
Prepared By:      
Signature:      
Title:      
IMPORTANT NOTICE - Under 15 U.S.C. 645(d), any person who misrepresents a firm’s status as a small business in order
to obtain a subcontract that is to be included as part or all of a goal contained in a subcontracting plan required pursuant to
Section 8(d) of the Small Business Act, shall (1) be punished by imposition of a fine, imprisonment, or both; (2) be subject to
administrative remedies; and (3) be ineligible for participation in programs conducted under the authority of the Act