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New Client Registration and Minority Business Directory application
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Company name |
Name of person completing form |
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Email Address |
Title of person completing form |
| Ethnicity | African American Puerto Rican, Spanish-speaking American; Aleut; Asian & Pacific Islander American; Asian Indian; Native American; Eskimo; Hasidic Jew |
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Address |
City State Zip |
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Telephone number |
Fax Number |
| Disabled Veteran? | No Service Disabled Veteran Disabled Veteran |
| Business start date & state of incorporation |
Date State |
| Legal Structure (C-Corp, etc) | |
| Describe your industry | |
| Describe product/services | |
| States where your business can provide services | |
| Number of employees | FT PT Minority |
| Annual Sales/Revenue | |
| Does your company accept the Government Credit Card (Visa)? | Yes No |
| Value of largest single contract in the past 3 years | |
| CCR Registrant? | Yes No |
| Minority-Owned Business Certification? | Yes No |
