Business Intake Form

Business Name:

EIN:

Dun and Bradstreet #:

NAICS Code - North American Industry Classification Systm:

*Find NAICS Code: https://www.census.gov/naics/

Primary Contact Name (First Last):

First Name

Last Name

Title:

Email:

Secondary Contact Name (First Last):

First Name

Last Name

Title:

Email:

Is your business currently operating?

If yes, numberof years opened:

Current Physical Business Address:

Address Line 1

City

State

Zip Code

Current Business Mailing Address:

Address Line 1

City

State

Zip Code

Are your business premises:

Company or Fictitious Name Rgistered?

If yes, date registered

Is Business Licensed:

If yes, City/County licensed in:

Type of Ownership:

How long have you owned the business?

What percentage of the business do you own?

Geographic Market

Website:

Are you a US Citizen:

Ethnic group membership:

If other explain:

Describe how you started the business:

If other explain:

Type of Business (Check all that apply):

If other explain:

Number of Employees:

Full Time:

Part Time:

Seasonal:

Contract (1099):

Total Employees:

Which of the following Certifications are you interested in obtaining (check all that apply)

National Certifications:

City Certifications City Name:

City Certifications:

State Certifications State Name:

State Certifications:

*Includes Standard Certification, Rapid Certification and Out of State Certifications.

Federal Certifications:

Are you registered in SAM for federal contracting?

Do you currently hold any other diverse certifications:

Please list any other specifics about your business that we should know: