Company Name:

Name of Primary Contact/Authorized Signatory:

E-Mail

Business Address:

City:

State:

Zip:

Phone No:

Fax No:

Tax Identification or Social Security Number:

Public

Private

Partnership

Corporation

Subsidiary

Franchise

Sole Proprietor

Remittance Address

City:

State:

Zip

Remittance Contact Name

Phone No:

State:

E-Mail:

Order Distribution Contact No:

Phone:

Fax:

E-Mail where open orders should be sent:

Check all that apply. To Qualify You must be 51% Owned and Operated by One of the following groups.

African American:

Hispanic American:

Native American:

Asian-Indian American:

Disabled/Veteran-Owned:

Women Owned:

Asian-Pasific American:

Indicate your top 5 niches or specialty skill sets in recruiting

1

2

3

4

5

Check all that apply. To Qualify You must be 51% Owned and Operated by One of the following groups.

Local

Regional

National:

International

Specific Regions

Northeast

Southeast

Mid-Atlantic

Western

Midwest

Specific States

Specific Countries (if International )