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Supplier Registration Form
Once you have reviewed Panasonic’s supplier qualification requirements and assessed your company's qualifications based on the information provided, please complete the form and register for possible consideration. Please fill out all information below and press “Send Email”:

Company/Contact Information
Company Name:
Other Name Being Used:
Street Address 1:
Street Address 2:
City:
State:
Postal Code: -
Contact Name:
Contact Title:
Headquarters? Yes No
Year Established:
Telephone: - -
Email:

Business Information
Parent Company:
Former Company Name:
Business Form:
Type of Ownership:
Primary SIC Code:
NAIC Code:
D&B Code:
Services/Products Offered:
Specific Geographical Service Area:
Number of Locations:
Number of Employees:
Website URL:

Financial Information
Latest Statement Date: (MM/DD/YYYY)
Annual Net Sales ($):
Cash & Equivalents ($):
Annual Gross Profit ($):
Current Assets ($):
Annual Operating Income ($):
Total Assets ($):
Annual Net Income ($):
Current Liabilities ($):
Retained Earnings ($):
Tax ID Number:
SBA/MWSDVBE Information
SBA Certified? Yes No
SBA Certificate Number:
SBA Date: (MM/DD/YYYY)

Percent Ownership
African American: Female: Male:
Asian Indian American: Female: Male:
Hispanic American: Female: Male:
Asian Pacific American: Female: Male:
Non-Minority Women:
Service Disabled Vet: Female: Male:
Native American: Female: Male:

Customer Reference (please provide 3)
Company 1 Name:
Telephone: - -
Contact Name:
   
Company 2 Name:
Telephone: - -
Contact Name:
   

Company 3 Name:

Telephone: - -
Contact Name:


Accomplishments & Comments:

I understand that completing this Supplier Registration Form does not, in and of itself, approve, qualify, or guarantee business with Panasonic.

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