Application for Information or Services
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Company Name:
Point of Contact:
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Dr.
Mr.
Mrs.
Ms.
Rev.
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II
III
Jr.
Sr.
Position Title:
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N/A
CEO
Employee
Marketing Exec.
Partner
President
Sales Exec.
Secretary
Sole Proprietor
Treasurer or CFO
Vice-President
Congressional Rep
EDC Professional
Judicial Representative
Legislative representative
State Representative
Federal Rep.
Other State or Local Rep.
Other
Banker
SBA Rep
Mailing Address:
City:
State:
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FM
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MH
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PW
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
Zip:
County:
Same as Mailing Address:
Physical Address:
City:
State:
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FM
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MH
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PW
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
Zip:
County:
Work Phone:
Fax:
Cell Phone or Pager:
E-Mail Address:
URL/Web Address:
Avg # of Employees (last 3 yrs):
Avg Yearly Gross Sales (last 3 yrs):
Date Business was Established:
[YYYY-MM-DD or MM/DD/YY]
DUNS Number:
CAGE Code:
Search for your DUNS Number and CAGE Code
Owner's Years Experience in Field:
Have you previously done business with any government agency or prime contractor?
Yes
No
Don't Know
Generally describe or list the Products or Services you wish to offer to the government:
List the types of services you might want to receive from our center:
How did you hear about us?
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N/A (NA)
Word of Mouth (01)
Twitter
Facebook
APEX Accelerator Event of Interest
Conference/Trade Show Event
APEX Accelerator
Bank (02)
Newspaper (03)
Chamber of Commerce (04)
Internet/Website (05)
Radio (06)
Television (07)
Magazine (08)
Other (09)
SBA (10)
Business Owner (11)
Educational Institution (12)
Local Economic Development (13)
Other Client (14)
Other:
By submitting this form, I acknowledge and certify that the information provided is true and correct.