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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NA - NA
CEO - 01
Employee - 02
Marketing Exec. - 03
Partner - 04
President - 05
Sales Exec. - 06
Secretary - 07
Sole Proprieter - 08
Treasurer or CFO - 09
Vice-President - 10
Congressional Rep - 11
EDC Professional - 12
Judicial Representative -13
Legislative representative - 14
State Representative - 15
Federal Rep. - 16
Other State or Local Rep. - 17
Other - 18
Banker - 19
SBA Rep - 20
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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APEX Accelerator
APEX Accelerator - Other - 50
APEX Accelerator - PA APEX Accelera
Bank - 02
Board Member - 16
BOP-Allenwood - 18
BOP-Lewisburg - 17
Business Owner - 11
Chamber of Commerce - 04
Covation Center - 78
DDC-New Cumberland - 22
DLA Website - 15
Educational Institution - 12
HACC - 99
IMC - 20
Internet - 05
Legislative - 25
LETTERKENNY SBS - 66
Local Eco Development Official - 13
Magazine - 08
MANTEC - 30
NA - NA
NAVSUP-SBS
NEPIRC
Newspaper - 03
Other - 09
Other Client - 14
OTS Prime Contractor
PA DGS
PENNTAP - 45
Radio - 06
SBA - 35
SBA - Other - 60
SBA - PCR - 65
SBDC - Bucknell - 70
SBDC = PSU - 75
SBDC KUTZTOWN - 71
SBDC LOCK HAVEN - 72
SBDC Shippen - 76
SBLO - 80
SBS - Other - 85
SCORE
SEDACOG Export - 90
SEDACOG Finance - 95
SEDACOG ITG - 92
Television - 07
US GSA
Word of Mouth - 01
World Trade Center
Other:
By submitting this form, I acknowledge and certify that the information provided is true and correct.