Revised - Landstar

Landstar Small and Disadvantaged Business Purchasing
Landstar is committed to spending an appropriate percentage of its total annual dollar outlay for goods and services with Small
and Disadvantaged Businesses. Landstar also tracks its purchases from woman-owned, veteran-owned and minority-owned
businesses. While these commitments are made in cooperation with some of Landstar’s larger customers and to comply with
regulatory requirements, Landstar’s management believes that providing business opportunities to Women-Owned, Verteran-
Owned and/or Minority-owned Business Enterprises is a good business practice. Landstar is requesting the cooperation of
suppliers, contractors, and other businesses in this initiative. **Please assist us by offering the information below.
Business Enterprise Information
____________________________________________ ____________________________________________
COMPANY OR INDIVIDUAL NAME FID #
____________________________________________ ____________________________________________
DOING BUSINESS AS (DBA) PHONE NUMBER
____________________________________________ ____________________________________________
CITY, STATE and ZIP CODE CONTACT NAME
My business operates as: [ ] Sole Proprietorship [ ] Partnership [ ] Corporation
My business is a Woman-Owned Business Enterprise. [ ] Yes [ ] No
My business is a Veteran-Owned Business Enterprise. [ ] Yes [ ] No I am a Disabled Veteran
[ ] Yes [ ] No
My business is a Minority-Owned Business. [ ] Yes [ ] No
Please circle your ethnic background:
A = Asian-Pacific American B = African American H = Hispanic American I = Asian-Indian American N = Native American Indian
Is your business certified by an affiliate of the National Minority Supplier Development Council (NMSDC)? [ ] Yes [ ] No
Name of regional council you are certified through: _______________________________________________________
Please supply your Certification number: _________________________________
____________________________________________________________________________________________________
Date Print Name Signature
A date, printed name and signature are required for this Landstar MBE From to be considered valid.
**Returning the form to fax number 800-235-1071 is not necessary if you have answered NO to the Yes/No items above.
Ethnicity Definitions:
Asian-Pacific American: a U.S. citizen whose origins are from Japan, China, Taiwan, Korea, Vietnam, Laos, Cambodia, the Philippines, Samoa, Guam,
the U.S. Trust Territories of the Pacific or the Northern Marinas, Indonesia, Micronesia, or Polynesia.
African-American: a U.S. citizen having origins in any of the black racial groups of Africa.
Hispanic-American: a U.S. citizen of true-born heritage (true-born meaning “authentically” or “genuinely,”) from any of the Spanish-speaking areas of
Latin America of the following regions: Mexico, Puerto Rico, Cuba, Central America, South America, the Caribbean basin and the Iberian Peninsula.
Asian-Indian American: a U.S. citizen whose origins are in India, Pakistan, or Bangladesh.
Native American Indian: a U.S. citizen who is an American Indian, Eskimo, Aleut or native Hawaiian, and regarded as such by the community of which
the person claims to be part. Native Americans must be documented members of a North American tribe, band or otherwise organized group of native
people who are indigenous to the continental United States and proof can be provided through a Native American Blood Degree Certificate (i.e., tribal
registry letter, tribal roll register number.)
Notifying Landstar of your women-owned, veteran-owned, and/or minority-owned business status may yield benefits such as the use of your services in
the service activities Landstar offers to their major customers. **Please return this completed Landstar Minority Business Enterprise (MBE) Form for
recognition purposes. Any inquiries concerning this form may be directed to 800-872-9515.
QUALTP-MBE Form-US
Reissued: 04/30/09 Page 5