NIBA Business Development Pilot Program
Corporate Partner Participant Form
This form has been designed
to locate and recruit Tribal and non-Tribal enterprises interested in mentoring
Native owned businesses in the areas of Federal program certification, identifying
contacts for business development and contract opportunities, and other related
areas of expertise.
Survey Instructions: Please complete one survey per business. Please fax the completed form to NIBA at
(202) 547-0589.
Business Information:
1.
Name of Business_______________________________________________________________
2.
City, State
& Zip Code___________________________________________________________
3.
Mailing Address
________________________________________________________________
4.
Phone/Fax ____________________________________________________________________
5.
Email
________________________________________________________________________
6.
Contact Name
& Title ____________________________________________________________
7.
Contact Phone
(if different from above) ______________________________________________
8.
NAICS Code(s)
(SIC codes) ______________________________________________________
9.
Congressional
District ___________________________________________________________
9.
10. Certifications (circle all applicable): SBA 8A; SDB; HUBZone; Buy Indian; Other (please explain);
Not-Applicable ________________________________________________________
11. Type
of Business (circle all applicable)
High Tech Tourism Research & Development
Manufacturing Construction Natural Resources
Agriculture/Livestock Finance Wholesale Trade
Insurance Real Estate Fisheries
Transportation Public Utilities Service/Retail
Forestry Gaming Other (please explain)
_____________________________________________________________________________
12.
Location of
Business (please circle): On reservation;
Off reservation; Rural; Urban
13.
Women Owned
Business (please circle)? Yes or No
14.
What are the
business’s major products or services?___________________________________
_________________________________________________________________________________________________________________________________________________________
15.
Are you a member
of NIBA (please circle)? Yes or No
16.
Please provide a
brief description of your business and its products and services? __________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________
17.
Briefly discuss
why it is important for your business to participate in this program? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
18.
Would you like
to be listed in NIBA’s Indian business database, which will be available via
the web site to potential contracting companies and Federal agencies (please
circle)? Yes or No
Thank you for your participation.
We look forward to working with you!