Business Listing Application

Gender

Years of
Ownership

Ownership Role

Ownership
Percentage

Voting
Percentage

Company submitting application must be at least fifty-one percent (51%) owned,
operated and controlled by a Chickasaw citizen(s).

*Company Name:
Parent Company:


Physical Address
*Address Line 1:
Address Line 2:
*City:
*State:
*Zip:
	Physical address is home office


Mailing Address: (if different)
Address Line 1:
Address Line 2:
City:
State:
Zip:


*Phone:
Fax:
Website:
Email:
*Key Contact(s) Name:
*Key Contact's Title:
Employer's ID/ Federal ID#:
SSN (for Indv Only):
*Primary Classification:
*Geographical Market:

Please check any certifications that your company holds:

8(a) Certification	Minority(MBE)	Hubzone
SDB Certification	Woman Owned (WBE)	Disabled Veteran (DVBE)
National Minority Supplier Development Council

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

*Description:

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

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