Fillable City Based Business 06.05.18 SBDC Request for Consultation Form - 12-2013

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City Based Business 06.05.18 SBDC Request for Consultation Form - 12-2013

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The City Based Business 06.05.18 SBDC Request for Consultation Form - 12-2013 form is 2 pages long and contains:

  • 2 signatures
  • 39 check-boxes
  • 27 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Bridgeport

BROWSE CITY OF BRIDGEPORT (CT) FORMS

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CITY BASED BUSINESS
BRIDGEPORT BUSINESS LOCATION VERIFICATION
PART I: BUSINESS OWNER AND BUSINESS INFORMATION DATE____________
*1. Client Name (Last, First, MI) or Business Owners Designee
*2. Email:
*3. Name of Business:
*4. Business Phone:
*5. Street Address (business address)
*6. City:
*7. State:
P
ART
II: Type of Business
*9. (Choose Primary Business Category)
Carpentry Roofing Site Work Finance & Insurance Health Care & Social Assistance
Masonry Asphalt Utilities Wholesale Trade Accommodation & Food Services
Plumbing Concrete Information Public Administration Arts, Entertainment & Recreation
Electrical Welding Retail Dealer Educational Services Transportation & Warehousing
HVAC General contractor Manufacturing Real Estate & Rental & Leasing Professional, Scientific & Technical Services
Other ______________________________________________________________________________________________
Please provide a general description of the goods and/or services that your business provides:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
PART III: Is your business certified as any of the following? YES NO
*10.
MBE WBE SBE
If ‘YES’, please provide a copy of the certification
PART IV: Please provide two of the following documents to prove city based business
*11. Please check the box of each document provided (2 or more documents required):
Business utility bill Business telephone bill Past year’s Business tax return Connecticut Secretary of State C.O.N.C.O.R.D.
Copy of business mortgage statement or business location lease agreement Business/personal property tax bill Other_______________________________
I
certify and affirm:
The principals and/or the management operate the business from the above-stated address;
The business’ books and records are maintained at the above-stated address; and
I understand that final approval and continued validation may be subject to an interview and/or onsite visit;
All information provided as part of this application is true and correct to the best of my knowledge.
_
_______________________________________________________ _______________________
Printed Name Title
_
____________________________________________________________ ________________
Signature Date
O
FFICE USE ONLY
S
mall & Minority Business Enterprise has confirmed this business is a city based business.
YES NO
Type of Contact: Face to Face Online Telephone Primary Counselor: __________________________________________
_____________________________________________________________ ______________ ____________
Signature of SMBE Director or Program Manager Validation Date Expiration Date
T
HIS CERTIFICATE IS VALID FOR TWO (2) YEARS FROM THE DATE OF VALIDATION.
*
*Please Notify the SMBE Office if any changes occur with your City Based Business to update CBB status
FOR INTERNAL USE ONLY
FORM OF IDENTIFICATION
1.___________________
2.___________________
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City Based Business 06.05.18 SBDC Request for Consultation Form - 12-2013

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Completed 11 July 2020

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