Prospective Supplier

Company Name

Company Website

Street

City

State* Leave blank for non-USA addresses

Zip

Primary Contact First Name

Primary Contact Last Name

Primary Contact Phone

Primary Contact Mobile

Primary Contact Email

Number of Years in Business:

Annual Revenue (YTD & Previous Year):

Entity Structure Description:

Diverse Service Provider** At EQT, we believe that just as cultural diversity strengthens our communities, supplier diversity strengthens our company. That is why we are committed to providing qualified suppliers an equal opportunity to deliver goods and services that meet our business needs. If you are a certified or classified diverse business, please indicate as such in the respective box.

Scope of Services / Natural Gas Experience

Please provide a list of specific services/goods/equipment that your company is able to provide to EQT:

Department(s) to be Serviced:

Previous or Existing EQT Supplier:

Other Natural Gas Companies Working For:

Formal Safety Program:

ISN Registration Number:

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