Diversity & Inclusion Program Attestation Form

BloomNet Diversity Program Attestation Form

To join our BloomNet Diversity Program, please self-identify by completing our self-attestation form below indicating that you are at least 51% owned, operated, managed, and controlled by a member of one or more of these specific/designated diverse groups:

• Minority Owned Business*

*African American/Black, Asian American Pacific Islander (AAPI), Native American/Alaska Native, Latinx/Hispanic

• Disabled Owned Business

• LGBTQ+ Owned Business

• Veteran/Disabled Veteran Owned Business

• Woman Owned Business

Shop Code

First Name

Last Name

City

State

Phone Number

Mobile Number

My business identifies as:

Select all that apply.

Which state or local certifications you'd be interested in obtaining?

Select all that apply.

By checking this box, I opt in to the BloomNet Diversity Program, and agree to receive future marketing and communication materials, to help tell our story and drive increased awareness of our diversity-owned business.

OPT IN/AGREE

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