© 2022 Broadridge Financial Solutions, Inc., Broadridge and the Broadridge logo are registered trademarks of Broadridge Financial Solutions, Inc. broadridge.com CONFIDENTIAL INFORMATION Supplier Registration Form To participate in the Broadridge Supplier Diversity Program, a company must have a current third-party certification. If you qualify as a diverse business and possess a current certification from a certifying agency, you are invited to complete and submit a supplier registration form. To begin the registration process, please complete the following form. Send your completed registration form and a copy of your certification via email to supplierdiversity.procurement@broadridge.com. COMPANY INFORMATION Business Entity Name Address 1 Address 2 City State or Province Zip or Postal Code Country DUNS # Supplier Diversity Category (WBE, MBE, LGBTQ, etc.) Certification Expiry Date Owner's Ethnicities Product or Service Category (consulting services, maintenance, supplies, etc.) COMPANY CONTACT INFORMATION Prefix First Name Last Name Title Email Address Business Phone Extension Please be aware that this registration does not qualify you as an approved supplier. This step is the beginning of the process that allows your company information to be made available to Broadridge’s Procurement Team for potential opportunities. Supplier Registration Form COMPANY INFORMATION COMPANY CONTACT INFORMATION Business Entity Name: Address 1: Address 2: City: State or Province: Zip or Postal Code: Country: DUNS: Product or Service Category consulting services maintenance supplies etc: Prefix: First Name: Last Name: Title: Extension: Business Phone: Email Address: Owner's Ethnicities: Certification Expiry Date: Supplier Diversity Category (WBE, MBE, LGBTQ, etc: ):