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Supplier / Investor Pre-Qualification Information

Required fields are bold.
 

Section I. Business Section

Company Information
  Are you a Supplier or an Investment Firm?
 
 
  Legal Company Name:
 
Physical Address
  Address:
   
  City:
  State
  Zip / Postal Code:
 

Contact Information
  Contact Name:
  Title:
  Phone Number: Ext.
  Fax Number:
  E-Mail Address:
 
 

Section II. Business Biography
 
Select the Products/Services you are requesting invitation for or targeting investments in Remove From List
 

 
  Please provide a description of the products and services your company offers or provides investment capital for:
 
 
  What are the key differentiating attributes of your company that sets you apart from your competition:
(List up to five (5). No more than 100 words each.)
 
 
 
 
 
 

Last 3 Years Revenue or Capital Under Management
  2009:
  2008:
  2007:
 

Company Data
  How many years has your company been in business?
  How many employees do you have?
 
  How many locations do you independently operate within?
(Hold down ctrl key to select multiple)
 
US   International
 
 
  How many additional locations do you operate within when considering formal business partnerships?
(Hold down ctrl key to select multiple)
 
US   International
 
 
 

Section III. Certification Information
  Is your company certified by the National Minority Supplier Development Council (NMSDC) as a minority business enterprise (MBE)?
 
 
 
 
  Has your company raised investment capital? (angel investment, investment firm, private equity?)
 
 
  Do you anticipate a need for investment capital in the next
(Not applicable for investment company)
 
 
  Has your company successfully exited from a third-party investment?
(Not applicable for investment company)
 
 
  Have you been concerned with the loss of MBE status when considering raising/providing investment capital?
 
 
  Are you aware of the rules associated with how investment capital provided by certified minority investment companies qualifies towards ethnic minority ownership determinination?
 
 
  If invited, who would be attending the Capital Summit event (scheduled to take place November 2008)?
 
  Contact Name:
  Title:
  Phone Number: Ext.
  E-Mail Address:
 
  If space is available, who else would you want to attend?
  Contact Name:
  Title:
  Phone Number: Ext.
  E-Mail Address:
 
  What national trade or business-specific organizations are you a member of?: