Northwest Ohio PTAC
Application for Information or Services

  * Colored Fields are required
Company Name:
Point of Contact:
Position Title:
Mailing Address:
City:
State:
Zip:
County:
Same as Mailing Address:
Physical Address:
City:
State:
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:  &nbsp [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:
Business Ownership:
Check all that apply. (Defined as 51% owned and controlled.)
Woman-owned Minority-owned Veteran-owned
Service Disabled Veteran-owned
Business Certifications and Determinations:
Check all that apply.
Disadvantaged Business
Distressed
Certified HUBZone
Small Business

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?
    Other:

 
By submitting this form, I acknowledge and certify that the information provided is true and correct.