Minority & Women-Owned Businesses Registry Application

2. Company Legal Name*

4. DBA

6. Owner's First Name*

7. Owner's Last Name*

9. Business Physical Address*

   Must be within the city limits of the City of Michigan City and cannot be a PO Box.

10. Suite or Apartment Number

12. Mailing Address

    (if different from street address)

14. City*

15. State*

16. Zip Code*

18. Primary Phone*

19. Secondary Phone

21. Primary Phone Type*

    1. Home
    2. Work
    3. Mobile

22. Secondary Phone Type

    1. Home
    2. Work
    3. Mobile

24. Email Address*

25. Fax Number

27. Website Address*

28. SIC Code:

30. Total size of workforce*

    1. 1-6
    2. 7-14
    3. 15 or more

32. Are you currently registered as a minority or woman-owned business by the State of Indiana?*

    1. Yes
    2. No

33. If yes, what is your certification number?

35. Please describe the services and/or products that your company provides.*

Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit Submit and Print

* indicates a required field