Minority Business Registration Form

Name of Business

Phone Number

Federal Employee ID Number and/or Social Security Number

Type of Business

If Other, Explain:

Business Structure

Applying for Certified Status as a:

Minority Status of Owner(s)

Citizenship Status of Minority Owner(s)

If Other, Explain:

Is the Business Bonded?

Is the Business Insured?

Is the Business a Licensed Contractor to do business in the State of South Carolina?

If yes, what is the License Number?

Does the Business have a current Town of Summerville Business License?

If yes, what is the License Number?

Is the Business Certified 8(a) by the U.S. Small Business Association?

If yes, what is the Certificate Number?

Is the Business Certified by the S.C. Dept. of Transportation?

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

Choose how to sign

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I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

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