The University of Memphis
Minority/Ethnicity Form
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Submit form to: Procurement & Contract Serivces/Vendor Registration
The University of Memphis
115 Administration Building
Memphis, TN 38152

In order to comply with reporting regulations as required by the State of Tennessee and the United States federal income tax laws, it is necessary that the following information be provided prior to the issuance of any University contract.

Name of Contractor:

Federal ID / Social Security Number:

Is Contractor a US citizen?

Yes    No

If yes, include an authorized W-9.

If no, enter country of citizenship:

(If not a US Citizen, please include a copy of Visa and W-8 with this form.)

Excluded from Federal Procurement or Nonprocurement Programs?
Yes    No

Address:

(Line 1)
(Line 2)
(City)
(State, Zip)

Contact Information:

Phone number:

Fax number:

E-mail address:

Kind of Ownership (Select one):

Govt. (GO)
Agency of the State of Tennessee (SA)
Non-Profit (NO)
Majority (MJ)
Minority* (see reverse side for definition)
Women (WO)** (see reverse side for definition)
Small (SM)*** (see reverse side for definition)
Service-Disabled Veteran (DV)**** (see reverse side for definition

Minority/Ethnicity Code (Select one):

African-American (MA)
Native American (MN)
Hispanic American (MH)
Asian American (MS)

 

Preference for reporting purposes: (Note: If Contractor qualifies in multiple categories as small, woman-owned and/or minority, Contractor is to specify in which category he/she is to be considered for reporting and classification purposes.)

Small   Minority   Woman Owned   Service-Disabled Veteran

Certification:  I certify that all the information as completed above is accurate and true.

Name (Printed): 
Title:
____________________________________________
Signature
____________________
Date

   

 


*Minority Ownership Clarification:
"Minority owned business" means a business that is a continuing, independent, for profit business which performs a commercially useful function, and is at least fifty-one percent (51%) owned and controlled by one (1) or more minority individuals who are impeded from normal entry into the economic mainstream because of past practices of discrimination based on race or ethnic background. 

"Minority" means a person who is a citizen or lawful permanent resident of the United States and who is:

a)  African American (a person having origins in any of the black racial groups of Africa);

b)  Hispanic (a person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race);

c)  Asian American (a person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands); or

d)  Native American (a person having origins in any of the original peoples of North America).

 

**Woman Owned Business Clarification:
A "woman-owned business" means a woman owned business that is a continuing, independent, for profit business which performs a commercially useful function, and is at least fifty-one percent (51%) owned and controlled by one or more women; or, in the case of any publicly owned business, at least fifty-one percent (51%) of the stock of which is owned and controlled by one (1) or more women and whose management and daily business operations are under the control of one (1) or more women.

 

***Small Business Ownership Clarification:
A "small business" means a business that is independently owned and operated for profit, is not dominant in its field of operation and is not an affiliate or subsidiary of a business dominant in its field of operation.

The Governor's Office of Diversity Business Enterprise establishes small business guidelines on industry size standards.  The criteria guidelines are required to be met in order for a business to be considered small.  The annual receipts or number of employees indicates the maximum allowed for a small business concern and its affiliates to be considered small.

 

****Service-Disabled Veteran Business Enterprise (SDVBE) Clarification
Tennessee Service-Disabled Veteran owned mean any person who served honorably on active duty in the Armed Forces of the United States with at least a twenty percent (20%) disability that is service-connected meaning that such disability was incurred or aggravated in the line of duty in the active military, naval or air service. “Tennessee service disabled veteran owned business” means a service-disabled veteran owned business that is a continuing, independent, for profit business located in the state of Tennessee that performs a commercially useful function.
Tennessee Service-Disabled Veteran owned means a service-disabled owned business that is a continuing, independent, for profit business located in the state of Tennessee that performs a commercially useful function, and

  1. is at least fifty-one percent (51%) owned and controlled by one (1) or more service-disabled owned veterans;
  2. In the case of a business solely owned by (1) service-disabled veteran and such person’s spouse, is at least fifty percent (50) owned and controlled by the service-disabled veteran; or
  3. In the case of any publicly owned business, at least fifty-one percent (51%) of the stock of which is owned and controlled by one (1) or more service-disabled veteran and whose management and daily business operations are under the control of one (1) or more service-disabled veteran.
TYPE OF BUSINESS
ANNUAL GROSS SALES
NO. OF EMPLOYEES
Agriculture, Forestry, Fishing
$500,000
9
Architectural / Design / Engineering
$2,000,000
30
Construction
$2,000,000
30
Educational
$1,000,000
9
Finance, Insurance & Real Estate
$1,000,000
9
Information Systems / Technology
$2,000,000
30
Manufacturing
$2,000,000
99
Marketing / Communications / Public Relations
$2,000,000
30
Medical / Healthcare
$2,000,000
30
Mining
$1,000,000
49
Retail Trade
$750,000
9
Service Industry
$500,000
9
Transportation, Commerce & Utilities
$1,000,000
9
Wholesale Trade
$1,000,000
19