COMPANY NAME:
ADDRESS:
CITY:
STATE:
ZIP CODE:
PHONE:
FAX:
COMPANY WEB ADDRESS:
KEY CONTACT:
TITLE:
EMAIL ADDRESS:
YEAR ESTABLISHED:
NO. OF FULL-TIME EMPLOYEES:
D&B#
ANNUAL SALES (past 3 years)
GEOGRAPHIC SERVICE AREA
LOCAL
REGIONAL
NATIONAL
INTERNATIONAL
COMPANY CLASSIFICATION (CHECK ALL THAT APPLY)
SMALL BUSINESS CONCERN (AS NEEDED BY THE SMALL BUSINESS ADMINISTRATION)
MINORITY-OWNED BUSINESS AT LEAST 51% OWNED, CONTROLLED AND MANAGED DAILY BY ONE OR MORE U.S. CITIZENS BELONGING TO AT LEAST ONE OF THE FOLLOWING ETHNIC GROUPS:
BLACK
HISPANIC
ASIAN AMERICAN
ASIAN INDIAN
NATIVE AMERICAN
WOMEN-OWN BUSINESS AT LEAST 51% OWNED, CONTROLLED AND MANAGED BY A WOMEN OR WOMEN (U.S. CITIZENS)
IS THE BUSINESS CERTIFIED BY A THIRD PARTY ORGANIZATION, GROUP, OR AGENCY?
YES
NO
*PLEASE FAX A COPY OF YOUR CURRENT CERTIFICATION TO 740-549-4199
WHAT MAKES YOUR COMPANY STAND OUT FROM OTHER COMPANIES IN THE SAME INDUSTRY?
PRIMARY NAICS CODE(S) AND
DESCRIPTION(S):
PRIMARY SIC CODE(S) AND
DESCRIPTION(S):
HOW DID YOU LEARN ABOUT OUR PROGRAM?
REFERENCES
COMPANY NAME
CONTACT NAME
PHONE
NAME:
TITLE:
DATE:
