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