Legal Name of Business Address City, State, Zip   AK AR AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MS MO MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Owner or Contact Person's Name Email Address Telephone Fax Federal ID or Sole Proprietorship Type of Business Manufacturer Distributor Service Provider Courier/Transportation Other Please specify if Other Preferred Market Local Regional National International Year Business Established Business Classification (check all that apply) Large? Small? Bus Class Min? Small Disadvantaged? Woman-Owned?

Company Location and Facility Information Location Size of Facility No. of Employees

Company Officers Name Title

Principal Customers and Contacts Name Contact Telephone

Brief Description of Products or Services

Your Name Title Are you Certified?

Notes