Diverse Business Application Step 1 of 2 50% Contact Information Additional Information Business Name(Required)Legal Business Name (if different)Office Phone(Required)WebsiteNumber of Employees(Required)General Email Address Office Street Address(Required)Mailing Address (if different)Office City/State/Zip(Required)Mailing City/State/ZipContactsPrimary Contact Name(Required)Additional Contact NamePrimary Contact Title(Required)Additional Contact TitlePrimary Contact Direct Number(Required)Additional Contact Direct NumberPrimary Contact Email(Required) Additional Contact Email Liability Insurance LimitInsurance Expiration Date MM slash DD slash YYYY License NumberFederal Tax ID Number(Required)Preferred form of communicationEmailPhoneOther (please specify)Other form of communicationNeed assistance with this application? Contact us at diversesupplierinfo@evergreen.energy or (872)-298-4918. Contact Information Additional Information Union Status(Required) Union Non-Union Business Type(Required) Contractor Distributor Consultant, Energy Efficiency or Otherwise Marketing/Outreach Program Implementation or Management Engineering Services Other Other Business TypeDoes your business hold any of the following certifications?(Required) Certified Minority Owned Business Certified Woman Owned Business Certified Veteran Owned Business LGBTQ+ Certified Owned Business Certified Disability Owned Business None of the above *Certification will be requested after submitting this agreement.(Optional) Annual Revenue AmountDisclaimer: Revenue will impact which certification will be the best fit.(Optional) NAICS CodeClick here for more information.Is the business currently a registered Trade Ally of the Peoples Gas and North Shore Gas Energy Efficiency Programs? Yes No Is the business at least 51% directly owned, managed, and controlled by one of the more individual of a qualified diversity group, including minority, women, veteran, disabled, LGBTQ+? Yes No Qualifications for a Diverse Business CertificationHas the business owner ever previously received a certificate from an independent certifying body verifying that it is at least 51% directly owned, managed, and controlled by one or more individuals from a qualified diversity group?(Required) Yes No Please summarize previous certificationQualifications/Requirements for Business OwnersA. Is the business owner a member of any of the following minority groups:(Required) Asian (Including Indian subcontinent and Far east) Native Hawaiian or Other Pacific Islander Black or African American Hispanic or Latino American Indian or Alaska Native Other (please specify below) None of the above Prefer not to say Other minority groups:B. Does the business owner identify as a woman?(Required) Yes No Does the business owner have a disability?(Required) Yes No disability:IN list of disabilitiesDoes the business owner identify as LGBTQ+ (Lesbian, gay, bisexual, transgender, queer, or more)?(Required) Yes No Additional Business QualifactionsHas the business been operating for two years or more?(Required) Yes No Is the business registered to do business in Illinois?(Required) Yes No Is the business in good standing? If accepted to the Diverse Business Academy, business owner will be required to submit proof of good standing, business registration, and date of business inception.(Required) Yes No Please provide an overview of the company.(Required)If you'd prefer, you can also email this information to diversesupplierinfo@evergreen.energyPlease provide a short description of two customer projects completed by your business in the past year. Include the customer’s contact information in the boxes below.(Required)Customer 1 nameCustomer 2 nameCustomer 1 phoneCustomer 2 phoneCustomer 1 email Customer 2 email What are your goals or expected outcomes from participating in this program?(Required)Service Area(Required) City of Chicago Lake County Other (please specify) Other service areaProgram(s) of Interest(Required) Residential Multi-Family Commercial and Industrial Small Business 13. Business Service Offerings (Please select all that apply):(Required) Air Sealing/Insulation Appliances: Kitchen Equipment Compressed Air Controls: Building Automation Controls: Industrial Systems Duct Sealing Energy Auditing Energy Management Engineering Heat Recovery HVAC: Boilers HVAC: Furnaces New Construction Pipe Insulation Plumbing Process Heating Service and Maintenance Steam Ventilation Marketing Program Implementation or Management Outreach Engineering Services Other (please specify) Other Products and ServicesPlease list any relevant licenses, professional certifications and memberships here:Please list any non-English languages the business owner or key staff members are proficient in.Need assistance with this application? Contact us at diversesupplierinfo@evergreen.energy or (872)-298-4918. Email
