Small Business Registration Form

To proceed with registration, complete the form below. Once the registration form has been completed and submitted, your company's profile information will be added to an internal Wyeth database and will be available to appropriate personnel. Please note: Registration does not guarantee registrants that their company will be identified, contacted, evaluated, or selected to enter any business relationship with Wyeth. Moreover, registrants' interaction with the site or subsequent contact by Wyeth, if any, shall not be deemed to construe any promise whatsoever by Wyeth to transact business with suppliers who register.

This site is not to be used to report an Adverse Event and will not be monitored for Adverse Event reports.

Small Business Types (Check all that apply.)

For a description of small businesses, read the small business guidelines and certification information.

^*Indicates required fields

	Large Business
	Small Business
	Small Disadvantaged Business
	Note: If you select Small Disadvantaged Business, you are required to enter your certification information in the fields below.
	Certification Number	Certification Start Date	Certification End Date
	Minority-Owned Business
	Minority Business Enterprise (MBE)-Certified
	Note: If you select MBE, you are required to enter your certification information in the fields below.
	Certification Number	Certification Start Date	Certification End Date
	Small Women-Owned Business
	WBENC-Certified Women-Owned Business
	Note: If you select WBENC, you are required to enter your certification information in the fields below.
	Certification Number	Certification Start Date	Certification End Date
	HUBZone Small Business
	Note: If you select HUBZone Small Business, you are required to enter your certification information in the fields below.
		Certification Start Date	Certification End Date
	Small Veteran-Owned Business
	Small Service-Disabled Veteran-Owned Business

Today's Date

Company's Name*

Company's Web Site Address

Company's Address

City

State/Region

ZIP Code

Contact Name*

Contact Title

Please indicate your preference for contact*

Phone

E-mail

Contact Phone Number

Contact E-mail Address

DUNS Number*

Data Universal Numbering System (DUNS) is a unique nine character ID number provided by the commercial company Dun & Bradstreet (D&B). For more information, call D&B at 866-705-5711.

NAICS Code

North American Industry Classification System (NAICS) is used by the SBA to identify the small business size requirements. For more information, visit http://www.census.gov/epcd/www/naics.html.

  

217011-01