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*, Disabled Owned Business, LGBTQ+ Owned Business,
Veteran/Disabled Veteran Owned Business, Woman Owned Business

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

Diversity Inclusion Form

Member Type

Name(Required)

First Last

Email Address(Required)

Shop Code(Required)

City(Required)

State(Required)

Phone Number(Required)

Mobile Number

My Business Identifies as:

Which state or local certifications would you be interested in obtaining?

African American/Black
Asian American Pacific Islander
Native American or Alaska Native
Latinx/Hispanic
Disabled Owned Business
LGBTQ+ Owned Business
Veteran Disabled Owned Business
Woman Owned Business

MBE (Minority Business Enterprise)
DOBE (Disability-Owned Business Enterprise)
LGBTBE (LGBTQ+ Business Enterprise)
VBE (Veteran Business Enterprise - including SDVBE & VDOBE)
WBE (Women Business Enterprise)

BloomNet® Diversity Program Attestation Form

Diversity Inclusion Form

BloomNet^® Diversity Program Attestation Form