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Request for Services
Please complete the form below to request for services:
Name
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
Cell
Email
Gender Identification
Female
Male
Non-Binary
Other
Prefer Not To Say
Minority/Ethnic Classification
African American
Asian American
Asian Indian
Asian Pacific American
Aleut
Eskimo
Native American
Hasidic Jew
Hispanic American_
Puerto Rican
Other
Prefer Not To Say
Services Requested
Business Plan Development
Construction Assistance
Franchise Development
Other Financial
Loan Packaging
Procurement Assistance
Marketing
Strategic Planning
Market Research/Feasibility Analysis
Other
Requesting a Loan
Yes
No
Company Info
Company Name
Company Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Email
Website
Business Start Date
MM slash DD slash YYYY
Accounting Period Closes (Mo)
Business Type
C Corporation
Partnership
LLC
Subchapter S Corp
Partnership
Sole Proprietorship
American Indian Tribe
State Government Entity
College
University
Local Government Entity
Other For Profit
Other Non-Profit
State of Incorporation
Is your business Minority certified (MBE)?
Yes
No
If yes, please indicate with which agencies:
Clark County
State of NV
NDOT
8(a) Federal
City of LV
NMSDC
Type of Business
Check all that apply
Manufacturing
Service
Construction
Retail
Franchise
Keywords (that best describes your business)
Number of Full-Time Employees
Number of Part-Time Employees
Number of Minority Employees
Annual Sales $
Annual Export Sales $
Largest Contract Value (In last 3 years)
Maximum Bonding Level $
Current Bonding Level $
Accept Government Credit Card
Yes
No
Facilities Security Level
None
Top Secret
Secret
Confidential
Other
Duns#
Value Added Network #
CAGE Code
Consent
This form demonstrates my company's intent to be a Client of the Nevada MBDA Business Center, and is not a binding contract between the parties. Nevada MBDA Business Center will provide assistance to me as agreed upon by my company and Nevada MBDA Business Center. Assistance is detailed in service agreements which are executed between the parties. I verify that the information provided above is accurate to the best of my knowledge.
Full Name
Signing Date
MM slash DD slash YYYY
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