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Business Profile
Company:
Parent Company:
Address:
City/State/ZIP: ,
Phone: (### ###-####)
Fax: (### ###-####)
Web Address:
Key Contact:
Name:
Title:
Email Address:
Year Established:
Number of Employees:
Federal ID # OR Social Security #:
Dun & Bradstreet #:
Annual Sales (Past 3 Years):
2002:
2003:
2004:
Geographic Service Area:

Local

Regional

National

International
If Regional or Local, specify service area(s):
Company Category:

Corporation

Partnership

Proprietorship

Joint Venture

Franchise
Type of Business:

Distributor

Broker

Service

Manufacturer

Consultant

Construction

Manufacturer's Rep

Retailer

Wholesale
Company Classification:

Minority-Owned business at least 51% owned, controlled and managed by one or more US Citizens belonging to at least one of the following ethnic groups:

 African American

Hispanic American

Asian Pacific American

Asian Indian American

Native American (Only American Indian; Aleuts; Eskimo; Native Hawaiian)

Small business concern (as defined by the Small Business Administration)

Small Disadvantaged business concern (certified by the Small Business Administration's certification program)

Woman-Owned business at least 51% owned, controlled and managed by a woman or women (US Citizens)

None of the Above
Yes No

Is the business certified by the Small Business Administration (SBA) or a recognized SBA certifier?
If Yes above, A copy of your current (within prior 12 months) SBA Certification must be enclosed with this form.
Yes No
Certified by a third party organization, group, or agency?
If Yes, provide the name(s) of the certifying organization(s)
NOTE:  For Minority or Women-Owned businesses, a copy of this certification must be returned with this form.  Certification must be made within the prior 12 months.  This profile will be considered incomplete without the certification form.
Primary SIC Code(s) and Description(s):
Yes No
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Last Modified: 12/27/2006 1:00:15 PM