Business Name:

Address:

City: State:   Zip:

Telephone: Fax:

E-mail:

Website:

Owner/Contact:

Are you currently a member of the Mobile Area Chamber of Commerce?

                                            Yes No

Please provide a brief description of your business activity, primary products and/or services. (100 words or less)

Describe your company's existing goals in dollars or percentage for utilizing local minority-owned businesses.

List and describe future changes in your procurement that will help facilitate continued progress in developing new and innovative minority-owned recruitment.

Community Contributions: List other local community service activities for your company and your involvement.

Provide details of any existing program or future plans to mentor or partner with a local minority-owned business.

Financial Data  
Financial information is an important quantifiable indicator of success for the judging panel, therefore, it is required the Financial Data Section be completed in full. All financial information provided will be used exclusively by the judging panel and solely for consideration for the Minority Business Advocate of the Year Award. Financial information will be kept strictly confidential and will not be released. These figures should include contracts to local minority-owned businesses.

Fiscal Year-End       Contract Amount to           Charitable Contributions
                            Minority-Owned                to Minority Community
                            Businesses (2010)            (2010)
Minority Group
African-American       $       $
Women-Owned          $       $     
Other                        $       $
Total                         $       $

Total local expenses for fiscal year 2010  $

Authorization and Consent
If I am selected as a Minority Business Advocate of the Year award winner, I hereby authorize the use of my name, my company's name, non-financial information, photographs, video recordings and audio recordings of me from whatever source, in connection with the Mobile Area Chamber of Commerce's Minority Business Advocate of the Year Award program. I agree that no compensation shall be due me or my company for such usage.

Truth of Information Release
By submitting, I agree that to the best of my knowledge the information provided herein is true and complete.

For more information contact Danette Richards at 251-431-8652