Directory of Business Owners Listing Form

First Name:
Last Name:
Title:
Company Name:
Main Office Address:
City:
State:	N/A Alabama AlaskaArizona ArkansasCaliforniaColorado ConnecticutDelaware District of ColumbiaFlorida GeorgiaHawaiiIdaho IllinoisIndianaIowa KansasKentuckyLouisiana MaineMarylandMassachusetts MichiganMinnesotaMississippi MissouriMontanaNebraska NevadaNew HampshireNew Jersey New MexicoNew YorkNorth Carolina North DakotaOhioOklahoma OregonPennsylvaniaPuerto Rico Rhode IslandSouth Carolina South DakotaTennesseeTexas UtahVermontVirginia U.S. Virgin IslandsWashington West VirginiaWisconsinWyoming
Country
Zip/Postal Code:
Phone:
Fax:
Email:
Web Site:
Are you a woman-owned business?	Yes No
Is your background Asian/Pacific American?	Yes No
Do you have WBE/MBE Certification?	Yes No
Certifying Organization:
Description of Organization (maximum of 50 words): Note that other directory users will be searching for companies by inputting words to describe the companies they seek; people will be more likely to find you if you use common keywords to describe your company or services.
Year you started your business
Number of Employees:
Annual Gross Revenues:	$50,000 and under $50,000 to $100,000 $100,000 to $250,000 $250,000 to $500,000 $500,000 to $1,000,000 $1,000,000 to $2,000,000 $2,000,000 to $3,000,000 $3,000,000 to $5,000,000 $5,000,000 to $10,000,000 $10,000,000 to $20,000,000 $20,000,000 and over

Please check the category that best describes your business:

Manufacturing

Wholesale

Retail

Service