Business Directory Application | Chickasaw Business Network

*Company Name:

Parent Company:

Physical Address

*Address Line 1:

Address Line 2:

*City:

*State:

*ZIP Code:

Physical address is home office

*Phone:

Fax:

Website:

*Email:

*Key Contact's Name:

*Key Contact's Title:

Employer's Federal Tax ID#:

SSN (For Indv Only):

*Primary Classification:

*Geographical Market:

*Type of Legal Business Structure:

Please check any certifications that the company holds.

8(a) Certification

Minority (MBE)

Hubzone

SBD Certification

Women Owned (WBE)

Disabled Veteran (DBVE)

National Minority Supplier Development Council

Business Description

Please give a concise description of the company products, services, or type of construction. If the company offers more than one product or service, list primary products or services first.

*Description (max 300 characters):

Owners/Stakeholders

Please list each owner, proprietor, partner, officer, member, director and stockholder. The name listed should include Minority Group Members and Non-Minority Group Members.

*Name:

*Title:

*Ownership Role:

*Gender:

*Years of Ownership:

*Ownership Percentage:

*Voting Percentage:

Chickasaw Business Directory - Business Directory Application