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Buyer Login Request
Name
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First
Last
Email
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Phone Number
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Job Title
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What is Your Position Type?
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Select
Buyer (On-Premise)
Buyer (Off-Premise)
Supplier Diversity Procurement
Please select from the following:
(Required)
Select
Restaurant
Hotel
Bar
Casino
Club
Stadium
Other
Please select from the following
(Required)
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Grocery
Wine, Spirits, Beer Retailer
C-Store
eCommerce
Other
LinkedIN Profile URL
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For validation purposes, please share with us your LinkedIN profile URL. If you do not have a LinkedIN, please share another digital source of confirmation (ie: you bio on company website).
How did you hear about us/Referred by:
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Company Information
Company
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Number of Buyers
(Required)
1-2
3-10
11-20
21-50
50+
Store Count
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Coverage Area
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i.e.:U.S. national buyer, U.S. specific region, Canada, France, etc.
If U.S., in what state are you located?
If U.S., what distributors do you use?
Supplier Diversity Program Information (as applicable)
Do you currently have a Supplier Diversity Program that includes diverse-owned businesses?
(Required)
Yes
No
If Yes, please include your Supplier Diversity Manager/Director’s name, title, email, phone:
If yes, please include your Supplier Diversity Initiative Website URL :
If Yes, do you: Require third-party certification?
Yes
No
If No, do you have a plan to implement?
Yes
No
Unsure
Why are you interested in the Diverse Powered Brands and how will it assist your business goals?
(Required)
Permission to use statement above as a testimonial on website, press release, media?
(Required)
Yes
No
If Yes, permission to use:
First Name, Last Name, Title, Company
First Name, Title, Company
First Name, Company
Title, Company
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Name
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First
Last
Email
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Phone Number
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Company
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Job Title
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How Did You Hear About Us?
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Administrator
Your Diverse Powered Brands account Administrator will be given admin access to the marketplace and will be responsible for creating and managing your company and brand pages.
Admin Name
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First
Last
Admin Email
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Credit Card
Card Details
Cardholder Name
Promo Code
Total
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