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3.

Business Mailing Address  

City

State

County

Zip

4.

Physical Address of Business

City

State

County

Zip

5.

Tax Identification Number

6.

Date business was established under present name and ownership:

7.

Is this business a continuation of a pre-existing business? Yes ___ No____; If yes indicate name(s)

8.

Indicate if this firm has previously been certified or participated as a DBE / MBE / WBE. Indicate the name of the certifying authority and provide a copy of the certification letter/certificate.

Certifying Authority

Address

Date

9.

Is the business affiliated with another business?

Yes ____    No  _____

If yes, list Name and Address of the affiliate firm.

10.

Business Structure

         (CHECK ONE):

PROPRIETORSHIP

PARTNERSHIP

LIMITED LIABILITY (LLC)

GENERAL CORP (INC)

11.

Please list three company and/or client references:

COMPANY

CONTACT PERSON
TITLE
TELEPHONE

12.

Identify four or less of your major products/services

PRODUCT OR SERVICE

PROVIDE A BRIEF DESCRIPTION:

1.

2.

3.

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