Section 1 of 1 in this document
Minority Business Registration Form
Name of Business
*
Business Point of Contact
First Name
*
Last Name
*
Phone Number
Email
Business Address
Street Address
*
City
*
State
*
Zip
*
Mailing Address (if different from above)
Street Address
City
State
Zip
Federal Employee ID Number and/or Social Security Number
*
Type of Business
*
Choose One
Manufacturing
Service
Broker
Construction
Distributing
Other
If Other, Explain:
Business Structure
*
Choose One
Sole Proprietorship
Partnership
Corporation
Joint Venture
Applying for Certified Status as a:
*
Choose One
Minority Owned Business (MBE)
Woman Owned Business (WBE)
Minority Status of Owner(s)
*
Choose One
Black
Asian
Hispanic
Aleut
Native American
Eskimo
East Indian
Caucasian Female
Citizenship Status of Minority Owner(s)
*
Choose One
United States
Resident Alien
Other
If Other, Explain:
*
Is the Business Bonded?
*
Choose One
Yes
No
Is the Business Insured?
*
Choose One
Yes
No
Is the Business a Licensed Contractor to do business in the State of South Carolina?
*
Choose One
Yes
No
If yes, what is the License Number?
Does the Business have a current Town of Summerville Business License?
*
Choose One
Option 1
Option 2
Option 3
If yes, what is the License Number?
Is the Business Certified 8(a) by the U.S. Small Business Association?
*
Choose One
Yes
No
If yes, what is the Certificate Number?
Is the Business Certified by the S.C. Dept. of Transportation?
*
Choose One
Yes
No
If yes, what is the Certificate Number?
Use this section to provide detailed information about the services and/or products offered
*
How many Full Time and Part Time employees do you have on Payroll?
*
What geographical area do you serve?
*
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First Name
Last Name
Email
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