Arkansas APEX Accelerator

Intent to Receive PTAC Client Services

* Colored Fields are required Company Name: Point of Contact: Please choose... Auth Dr. Mr. Mrs. Ms. Rev. Please choose... II III Jr. Sr. Position Title: Please choose... 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 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: Same as Physical Address: 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: 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: 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? Please choose... N/A Word of Mouth APEX Accelerator Bank Newspaper Chamber of Commerce Internet Radio Television Magazine Other - Describe Below SBA County Extension Agent Congressional Office Legislature Office SBDC Training Event NCMA GSA OSDBU (Fed Agcy SB Off) SBLO (Corp SB Liaison Off) Supplier Development Council LR Air Force Base APAC Client Other APEX Accelerator Employee of CES or APAC Army Corps of Engineers Other Federal Agency Outreach Event City or County Offices AR State Agencies APAC Literature     Other:

Agreement of Understanding

By submitting this form I, the undersigned, certify that neither my company nor any of its officers appear on the Federal Government's Excluded Parties List. I realize that no contracts or sales can be guaranteed from Arkansas Procurement Assistance Center PTAC (Procurement Technical Assistance Center) services and that Arkansas Procurement Assistance Center PTAC services are not to be considered legal advice or counsel. Completion of bids, offers, and pricing are the sole responsibility of my business / organization. Arkansas Procurement Assistance Center PTAC makes no representation or warranty as to the completeness or accuracy of any material or information provided. I agree that Arkansas Procurement Assistance Center PTAC, its host organizations, and resource partners are not responsible for any consequential or any other damages arising out of or in connection with the use of any such materials or information. In consideration of the furnishing of services and technical assistance, I waive any and all claims against Arkansas Procurement Assistance Center PTAC and its staff. I hereby agree to release and hold harmless the University of Arkansas, it's Division of Agriculture, the Cooperative Extension Service, the Arkansas Procurement Assistance Center, and their current and formal trustees, representatives, agents, officials, officers, and employees from any liability, any and all claims, demands, or any cause of action, arising out of or connected with participation, services, or assistance provided by the Arkansas Procurement Assistance Center. I agree that my organization will report information requested by Arkansas Procurement Assistance Center PTAC regarding contracts / subcontracts obtained as a result of assistance provided from Arkansas Procurement Assistance Center PTAC (directly or indirectly). Reports include Monthly Client Status Report, surveys, and success stories needed by Arkansas Procurement Assistance Center PTAC in accordance with the Department of Defense. I understand that information provided to Arkansas Procurement Assistance Center PTAC will be held in strict confidence and only provided to the Department of Defense as required and as appropriate to Congressional Offices to promote the program. By submitting this form I understand and accept this Agreement. Thank you for completing the Client Information Form. Hit "Submit Form" below to send the form to us.

Please check this box to verify you agree to the Agreement of Understanding then click Submit to complete your Intent to Receive PTAC Client Services.