Legal Name (Business or Owner)*

Doing Business As*

Mailing Address*

City*

State*

Zip*

Phone*

Fax

Email address

Are you a...*

Corporation Partnership Proprietorship

Individual Other

Companies may be certified with the State of North Carolina's Office of Historically Underutilized Businesses webpage at www.doa.nc.gov/hub.

Is your company Certified?

Yes

No

Product or service for sale*

Please upload any sales literature applicable