Hispanic Network Magazine

Print and return this form to: Hispanic Network Magazine, Attn: Amanda Roberts
22845 Savi Ranch Pkwy #A, Yorba Linda, CA. 92887, (800) 433-WORK, Fax (909) 924-1139

By submitting my Vendor Application I hearby authorize Hispanic Network Magazine and its affiliate companies to release the information to prospective companies. I further attest that the information provided is true and correct to the best of my knowledge. The information Provided will be used to assist my company in building a partnership with Corporate America.

Company Name:

Company Address

City/State/Zip:

Telephone/Fax/Toll Free:

E-mail Address:

What type of certification do you have:

Years in Operation:

Product/Service Offered:

Please Circle One:
Minority Owned
Women Owned
Disabled Veteran Owned

Small Business Owner
Disabled Owned

Type of Business:

List the names and addresses of three firms you have provided products/services during the past (3) years:

Name

Address

Contact Person

Phone Number

In 25 words or less, please summarize the supplies or services your firm provides:

For more infomation, or to reserve space please contact:
by e-mail Amanda Roberts
or by phone (800)433-9675