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2. Vendor Registration Form

   In accordance with the Illinois Public Act 102-0265, the Village of Deerfield is required to make a good faith effort to collect and publish certain demographic information provided by our vendors and subcontractors. We are now required to report whether the vendor or subcontractor is a minority, women, or veteran-owned business as defined by Illinois Law. In addition, we are required to disclose if the business is certified as a small business under Small Business Administration standards. We are kindly asking our vendors to provide us with current business information.

6. Vendor Name (as shown on tax return):*
7. DBA Name (if different from above):
9. Vendor Address:*
11. City*
12. State*
13. Zip Code*
15. Vendor Phone:*
16. Submitter Name:*
20. Business Type Classification Indicators*

    Please indicate your classification indicators as defined in the Business Enterprise for Minorities, Women, and Persons with Disabilities Act (select all that apply):

    1. Minority-Owned Business
    2. Women-Owned Business
    3. Veteran-Owned Business
    4. None of the Above
21. Classification Certification*

    For your selected classification categories, does your business hold any certifications? Or, are you self-certifying?

    1. Yes (official certification held)
    2. No
    3. Self-Certifying
    4. Not Applicable
23. Small Business Qualification*

    If you selected self-certifying as your certification classification, does your business qualify as a small business under Federal Small Business Administration Standards?

    1. Yes
    2. No

27. Data Access: Once data has been collected the Village will publish business demographic information on its official website.

    Questions: Should you have any questions regarding the vendor registration form, please contact Finance Generalist Valery McAvoy at vmcavoy@deerfield.il.us or 847.719.7436.

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29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

* indicates a required field