Walgreens Questionnaire – Fill Out and Use

Company: ______________________

Established Date: ___ / ___ / ____

Address: _______________________

Tax ID #: _____________________

City/St/Zip: _____________________

Duns & Bradstreet Listing #: _________

Telephone: ( __ ) ___ - ______

Are you a member of Uniform Product Council: Yes

No

Fax :

( __ ) ___ - ______

UPC Membership No: ____________

Sales Contact: ___________________

# of Employees: _____ # of Minority Employees: _____

Title: ___________________________

Are you a World Wide Retail Exchange member: Yes

No

Email Address: ____________________

Do you use EDI: Yes No

If yes, please check: PO

ASN Invoice Payment

EDI Comments:________________________

Company Background:

Type (check all that apply):

Ownership (please check):

Classification:

Represented by Broker: Yes No

Sole Proprietor: Yes

No

Male Owned %:

Manufacturer: Yes

No

Corporation:

Yes

No

Female Owned %:

Distributor: Yes

No

Partnership:

Yes

No

Service Provider: Yes No

Owned: Publicly Privately

Is your company certified as a Woman Owned business? Yes

No

Is your company certified as a Minority Owned business? Yes

No If Yes, please specify:_________________

Caucasian/White ____

Native Hawaiian ____

Pacific Islander ____

Black/African American ____

American Indian ____

Hispanic/Latino ____

Asian ____

Native Alaskan ____

Other: Please Specify____________________________________________________

Do you certify that the next 3 statements are all true: Yes

No

What is your target division: Walgreen stores

Walgreens.com

Have you shopped at Walgreen's stores: Yes

No

Where is your product made: %USA: ____ %Offshore: ____

Last Year's Sales Units: ___________

How long has it been on the market: ____________________

Last Year's Sales Dollars: ________

Brand Name(s): _____________________________________