Vendor Form, Delaware Racing Association, 777 Delaware Park Boulevard. Wilmington, DE 19804

Contact: Andrew Hoffman
tel: 302-994-2521 ext. 7365
e-mail: Andrew Hoffman

www.delawarepark.com

VENDOR FORM PAGE 1

Section 1: Business Information
Company Information

* Company Name

 



Doing Business As (If different from above)
* Address 1
Address 2
* City
* State
Province Region
* Zip/Postal
Country
* Contact Name
* Phone
Fax
* Email
Company Website

Section II Business Biography
Company Data

* Business Type

 

 

Service Area
Federal Tax ID

Diversity Information

Certification Type

 


Certification Agency
Certification Number
Certification Expiration Date
Diversity Category

License and Regulatory Information

Type License

 

Exception Code/License
Expiration Date
State Governing Body
CCC#(New Jersey)

*Required Field

 

   


The Delaware Council on Gambling Problems offers confidential assistance to gamblers, their families, and to those who are concerned about a friend or colleague. The Council provides literature, support meeting information, treatment information, and 24-hour help. Speakers are available for community groups and for professional training. HELPLINE 888-850-8888 | www.dcgp.org