MINORITY and WOMEN-OWNED SMALL BUSINESS DIRECTORY Mail: Fax: 1900 Kanawha Blvd., E Building 6, Room 652 Charleston, WV 25305 (304) 558-0127
TO BE COMPLETED BY WVSBDC:
Center:__________________________________ Client Number:___________________________ Date:____________________________________ SELECTIONS BELOW TO BE COMPLETED BY COMPANY:
Complete Bold Items. Mail or FAX to WVSBDC Please type or print Name of Firm: ________________________________________ POC: Mr./Mrs./Ms./Dr. ____________________________________________________ First MI Last Position: (CEO, etc.) _________________________ Owner : Mailing Address: ________________________________________ City: ________________________ State:_____________________ County: _____________________ Zip Code: _________________ Physical Address: (If Different) ____________________________ City: ________________________ State:____________________ County: _____________________ Zip Code: ________________ FEIN: (If in business) ___________-_______-________________ Work Phone: ________________ FAX: _____________________ Home Phone: ________________ Cell:______________________ Email 1:_____________________ Email 2:___________________ URL: _______________________ Select as appropriate: Disadvantaged Business Young Entrepreneur Small Business
Primary Industry Group (NAICS Codes and Titles)
(Select the group that best describes specific product or service)
1111-1153 Crop, Animal, Forestry, Fishing, & Hunting Production
3311-3399 Primary & Fabricated Metal Production
5511 Company and Enterprise Management Services 5611-5629 Facilities Support Employment, Mail, Travel, Waste Management, Security Services 6111-6117 Educational Services 6211-6244 Health Care & Social Assistance 7111-7139 Arts, Entertainment and Recreation 7211-7224 Accommodation & Food Services
2111-2131 Gas, Oil & Coal Extraction 2211-2213 Electricity, Gas, & Water Distribution 2361-2362 Building & Dev. Construction Services 2371-2379 Heavy Construction Highways & Bridges 2381-2389 Special Trade Contractors 3111-3169 Food, Clothes, Leather, Textiles, Apparel Manufacturing
4231-4251 Wholesale Trade 4411-4543 Retail Trade 4811-4931 Transportation & Warehousing 5111-5191 Publishing, Broadcasting, Film Sound, Telecom, Internet, Data Processing, Cable
Certified HubZone Woman-owned Business Located in Empowerment Zone
Organization Type: (Select one) Sole Proprietorship Corporation S Corporation LLC Partnership Not-for-Profit Average # Employees: ___________Where Incorporated? _________ Date of Incorporation___________ Describe function of the company: Specify products or services
5211-5259 Banking, Lending, Brokers, Securities, Insurance Services 5311-5331 Real Estate, Auto, Consumer, Office
Describe Owner of the Business: SBA Client: N/A Borrower Applicant 8(a) CofC Surety Bond Gender: Race: Black White Male Female Both
3211-3279 Wood, Paper, Printing, Chemicals, Products, Rentals Plastics, Rubber Nonmetallic Minerals Manufacturing 5411-5419 Legal, Accountant Architectural, R&D, Computer Systems, Consulting, Drafting, E ngineering Services
8111-8141 Repair & Maint., Personal and Laundry Services; & Religious, Civic, Social, Political Org, Private
American Indian/Alaskan Native Asian Native Hawaiian/Other Pacific Islander Other Minority ___________________________ Vietnam Era Vet Service Connected Disabled Vet
Military Status: Veteran Disabled Veteran
9211-9928 General Government Administration of Human Resources, Environment, Space, Economic, & Security Services
Hispanic International Trade AFDC Disabled TANF Home Based Business Veteran Owned Reservist called to active duty Net Worth:___________________ Bonded Amount: ___________________ Net worth as of (date) _________ Average Sales Amount: _____________________ National Minority Supplier Council Certified Women's Business Enterprise National Council Certified Form #5.4.1.40.40 Revision #5 Reference: Deputy Director
By checking this box, I hereby give consent to publish information I have
provided on this form for the on-line directory which I understand may be viewed by the general public. Signature _____________________________ Date ___________
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