Business Intake Form - Connectus World Wide

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- Diverse Business Services
- Corporate Services
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Leadership
- Mary Shannon
- Karen Slaughter
Contact

Business Intake Form

Please fill out this form in order to continue and expedite your services.

Business Name:*

EIN #:*

Business Profile:*

NAICS Code – North American Industry Classification System: *

*Find NAICS Code: https://www.census.gov/eos/www/naics/2017NAICS/2017_NAICS_Manual.pdf

Primary Contact Name:*

First

Last

Primary Daytime Phone:*

Primary Cell Phone:

Primary Email:*

Secondary Contact Name:

First

Last

Secondary Daytime Phone:

Secondary Contact Cell:

Secondary Email:

Is your business currently operating?:*

Yes

No

If yes, number of years opened:

Current Physical Business Address:*

Street Address City State / Province / Region Postal / Zip Code Country

Current Business Mailing Address:*

Street Address City State / Province / Region Postal / Zip Code Country

Is your Company or Fictitious Name Registered?:*

Yes

No

If yes, date registered:

Is Business Licensed?:*

Yes

No

If Yes, City/County licensed in:

City/County

Type of Ownership:*

How long have you owned the business?*

What percentage of the business do you own?*

Website:

Ethnic group membership:*

Asian Pacific

Black

Caucasian

Hispanic

Native American

Other

Describe how you started the business:*

Started it myself

It was a gift

I inherited it

Other

Type of Business (Check all that apply):*

Art Gallery/Studio

Construction

General Services

Manufacturing/Industrial

Office

Resturant

Retail

Technology

Transportation

Warehousing

Wholesale

Other

Is your company a registered Vendor with the City of Kansas City?*

Yes

No

Number of Employees:

Full Time:

Part Time:

Seasonal:

Total:

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

National Certifications:

WBENC- Women’s Business Enterprise National Council

NMSDC – National Minority Supplier Development Council

NABO – National Association of Women Business Owner

NWBOC – National Women’s Business Owner Corporation

City Certifications (enter city name below):

MBE - Minority Business Enterprise

WBE - Women Business Enterprise

DBE - Disadvantaged Business Enterprise

SBE – Small Business Enterprise

SLBE – Small Local Business Enterprise

City Name:

City

State Certifications (enter state name below):

MWBE – Minority Women Business Enterprise

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

State Name:

State / Province / Region

Federal Certifications:

8A Certification

HUBZone Certification

SDVOSB – Veteran and Service Disabled Veteran Certification

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

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