Company Name

Street Address

Tax Identification Number

Product/Services Offered
Architecture and Engineering ServicesBuilding Repairs - ElectricalBuilding Repairs - HVACBuilding Repairs - PlumbingConcrete repairDocument Printing and ReproductionFacilities - Fluid Pump Repair/ServiceGraphic DesignInformation Technology Products or ServicesJanitorial ServicesLandscapingLegal ServicesMarketingPaintingPlanning/Scheduling Consulting ServicesPublic RelationsSign Production and InstallationSite Pressure WashingSnow PlowingSupplier - FastenersSupplier - FiltersSupplier - Janitorial SuppliesSupplier - Light BulbsSupplier - LubricantsWebsite Design/ManagementTowingOther (please list)

Other - Products/Services Offered

Registered DBEYesNo

If Yes to Registered DBE
Black Americans, which includes persons having origins in any of the Black racial groups of AfricaHispanic American, which includes persons of Mexican, Portuguese, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of raceNative Americans, which includes persons who are American Indians, Eskimos, Aleuts, or Native HawaiiansAsian-Pacific Americans, which includes persons whose origins are from Japan, China, Taiwan, Korea, Vietnam, Laos, Cambodia, the Philippines, Samoa, Guam, the U.S. Trust Territories of the Pacific, and the Northern MarianasAsian-Indian Americans, which includes persons, whose origins are from India, Pakistan, and BangladeshWomen, regardless of race, ethnicity, or originOther, individuals found to be disadvantaged by the Small Business Administration Pursuant to Section 8(a) of the Small Business Act