DCMBEC LOGO
 
CONTACTUS
ABOUT US SERVICES CLIENTS EVENTS
CLIENT FORM

PRIMARY CONTACT INFORMATION

Name Date
Email Phone

COMPANY INFORMATION

Company Name   Phone
Address   Website
Address
cont'd
  Ethnicity of Principal Owner
City, State,
and Zip
     

BUSINESS INFORMATION

Business Type and Description
Number of
Employees:
Full Time: Part Time: Minority:
Business Start Date: Business Structure (Please choose one)
Corporation Sole Proprietorship     
Partnership LLC
Annual Sales:

DCMBEC Information Disclosure/ Minority Status


The purpose for collecting information is to track the development of the minority business for use in statistical surveys and other research. In that regard, the information entered into the form will be available to the general public.

In addition, information collected on this form will be made available to federal, state and local agencies for use in statistical surveys and other research to track the development of minority businesses. By entering data in this form you certify that you are authorized to make this information available to the public and agree to all the terms and conditions as specified herein.

E-Signature      Date

"I certify that I represent a Minority Business Enterprise. DCMBEC defines a Minority Business Enterprise as a business which is owned or controlled by socially or economically disadvantaged persons who are members of one of the following eligible groups: African Americans, Aleuts, Asian Indians, Asian Pacific Americans, Eskimos, Hasidic Jews, Native Americans, Puerto Ricans, and other Spanish-Speaking Americans. I understand that false certification may result in a fine or imprisonment under applicable Federal law.”

E-Signature      Date

  

  Ø Info@dcmbec.org  
HOME  |  ABOUT US  |  NEWS  |  EVENTS  |  SERVICES  |  CLIENTS  | FAQS  |  CONTACT US
Copyright © DCMBEC.ORG. 2007
All Rights Reserved.  Privacy Policy
 
powered by Photofunia