Northstar Lottery Group has more than 50 years combined Illinois experience
Northstar Lottery Group Supplier Pre-Qualification Form
Please complete this form to indicate your company's interest in supplier relationships with Northstar Lottery Group. All fields are required.
Company Name
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FEIN/SSN
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Address
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Street Address
Address Line 2
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Armed Forces Americas
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State
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Contact Person
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First
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Title/Position
Phone Number
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Fax Number
Email Address
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Website URL
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Type of Ownership (Please Select One):
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Sole Proprietorship
Partnership
Corporation
Limited Liability Partnership
Limited Liability Company
Limited Liability Corporation
Year Established
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Number of Employees
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Current Annual Sales
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Please list value only, no dollar sign ($) necessary
Type of Business
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Minority Business Enterprise
Disabled Business Enterprise
Women Business Enterprise
Veteran Business Enterprise
Not Applicable/Non-MWDBE
Company must be at least 51% owned and controlled by an individual or individuals who meet one or more of these business types. Please select all that apply:
Current MWDBE Certifications, if applicable (Select all that apply):
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State of Illinois Business Enterprise Program
City of Chicago
Cook County
Chicago Minority Business Development Council
Women's Business Development Center
None
Other
Please specify "Other" if checked above:
Please provide the following information for each owner/officer:
Name
First
Last
Title/Position:
Race/Ethnicity:
Gender:
Male
Female
Percentage of Ownership:
Please list value only, no percentage sign (%) necessary
Name
First
Last
Title/Position:
Race/Ethnicity:
Gender
Male
Female
Percentage of Ownership
Please list value only, no percentage sign (%) necessary
Name
First
Last
Title/Position:
Race/Ethnicity:
Gender:
Male
Female
Percentage of Ownership
Please list value only, no percentage sign (%) necessary
If you require more fields to complete the ownership information, please utilize this text box:
Please choose which industry best describes your business:
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Advertising/Marketing
Construction/Engineering/Facility Services
Distribution/Packaging
IT/Telecom
Non-IT Consulting/Professional Services
Printing/Office Supplies/General Business Services
Other
If "Other" is selected, please use "Products and Services" box below to describe your business in addition to listing products and services.
Products and Services:
Please provide a brief description of the products and services your company provides.
Terms and Conditions
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I have read and accept the Terms and Conditions
By checking the box, you agree that the information you have provided is true and you are able to provide submitted information as a representative of the company.
Name
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First
Last
Title/Position:
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Date
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Comments
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