PTAC Regional office for Cache, Box Elder, & Rich
Intent to Receive PTAC Client Services

  * Green Fields are required
Company Name:
Point of Contact:
Position Title:
Physical Address:
Same as Physical Address:
Mailing Address:
Work Phone:
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
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?

Request for Procurement Technical Assistance

On behalf of the company listed on this application, I request technical assistance to help obtain government contracts. I understand that the PTAC support services are available free of charge. I understand and agree to report information to my local PTAC personnel regarding government contracts, sub-contracts and/or government credit card purchases awarded to my company as a direct or indirect result of assistance provided by PTAC. Award information will be requested electronically monthly by PTAC and will include awarding agency, contract number where possible and dollar amount. The PTAC agrees to keep this and all other client information confidential.

The company I represent hereby waives its rights to any and all claims against Utah PTAC, Utah Governor's Office of Economic Development, organizations hosting PTAC sub-centers and any of their employees arising from services rendered. I further understand that my company bears all responsibility for decisions made and actions taken regarding doing business with government agencies and prime contractors.

Authorization of Referrals

From time to time, Utah PTAC is contacted by government agencies and prime contractors seeking small businesses. Information may be shared for the sole purpose of potential contracting opportunities or to gain exposure with that agency or business.

I hereby give permission for the Utah PTAC program to refer my company information to agencies and prime contractors.

By submitting this form, I certify the above information is correct.
 Please check this box to verify you agree to the Request for Procurement Technical Assistance and the Authorization of Referrals then click Submit to complete your Intent to Receive PTAC Client Services.