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Supplier Profile Form

Thank you for your interest in Halliburton's Supplier Diversity Program. Please note that information which you provide to Halliburton in the Supplier Profile will be used only by Halliburton and its affiliated business units for the purposes set forth herein and will not be disclosed to any outside party. Provision of this information and Halliburton's acceptance of your Profile does not guarantee that we will provide an opportunity to bid nor eventual selection as a qualified, approved Supplier. The Halliburton Procurement Department will carefully consider your Profile information when evaluating company procurement requirements and we may contact you for further information. However, we reserve the right to make all procurement decisions at our sole discretion.

Fields marked with an asterisk (*) are required.

Business Identification

*Company Name:
*Street Address:
*Zip Code:
Mailing Address:
Zip Code:
*Contact Person Name:
*Contact Person Title:
Telephone Number:
Fax Number:
*E-mail Address:
Web Page:
Parent Company Name:

Federal ID
*Primary SIC
Other SIC
Primary NAICS
Year Company Started: Number
of Employees:
Annual Sales Revenue:    

Business Class (Check All That Apply)

Large Minority-Owned
Small Women-Owned
Veteran-Owned Service Disabled Veteran-Owned

Business Ownership (Check All That Apply)

African American Asian Indian American Asian Pacific American
Hispanic American Native American Other

Certifications - Documents of Certification are Subject to Verification
(Check All That Apply, Supply Certificate Number)

Small Business (as defined by Section 3 of the Small Business Act)
Small Disadvantaged Business
Regional council affiliated with National Minority Supplier Development Council (NMSDC)
Regional council affiliated with Women's Business Enterprise National Council (WBENC)
Historically Underutilized Business (HUB)
Other - please specify:

  Municipal / State

When Contract Mandates, Can Your Company Provide the Following Safety and Insurance Information (Complete All That Apply)

  Year 1 Year 2 Year 3
OSHA Total Recordable Incident Rate (TRIR) for the
past three years
Number Lost Work Day Cases
OSHA Number of Recordable Incidents
Total Number Man Hours for Previous Year
Worker's Compensation Experience Modification
Rate (EMR for the three most recent years
Commercial General Liability Insurance with
limits of $2mm or greater
Automobile Liability Insurance with
limits of $2mm or greater

Products, Services, and Specialties Your Company Provides


How Did You Learn About Halliburton's Supplier Program?

Please Identify the Geographic Areas Served (Check All That Apply)

Gulf Coast Southeast Mid-Continent
USA Nationwide Rocky Mountain International

Top 10 Customers

Indicate Which Business Unit or Division of Halliburton You Have Done Business With in the Last 12 Months. Also Describe the Products/Services Provided, and the Buyer or Contact Name(s) (Complete All That Apply)

Business Unit/Division Product/Service Buyer/Contact Name(s)

Provide Current Halliburton Supplier Number (If Applicable)

E-Procurement Supplier Readiness

Do you currently have a Web presence and/or electronic catalogs for ordering?
Does the online store contain product specs & pictures?
Does the online store include customer specific pricing?
Do they include URL links to product specs?
Are your products cross-referenced to the UN/SPSC classification system?
Are you providing your electronic catalog to any third party providers?
What format is your catalog in? (flat file, cXML, etc.)

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