(“Minority Business Registered” shall mean a business which is an independent and continuing operation for profit, performing a
commercially useful function, and is owned and controlled by
one or more ethic groups. Business must also be located outside of the City of
Columbus MSA area.)
1. ____________________________________________________________ ________________________________________________
Company Name Federal Tax Id or Social Security Number
2. ____________________________________________________________ _______________________________________________
Type of Business (Corporation, Partnership, Sole Proprietorship) Date company was established
3. Type of Industry, (Please check all that apply): Construction
Professional Services
Goods Miscellaneous
4. Please describe the major activity of the company. Please be specific:
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
5. _________________________________________________________________________________________________________________
Business Street Address P.O. Box
________________________________________________________, __________________________________ ___________________
City State Zip
6. _________________________________________________ ____________________________ _______________________________
Owner Phone Number Fax Number
_______________________________________________________ ________________________________________________________
(E-mail Address) (Website Address)
7. Ownership Disclosure (Attach additional sheets if necessary):
Owner(s) Name
Gender
Minority Designation:
African-American, Women, Hispanic,
Asian,
Pacific Islander, American
Indian,
Alaska Natives
Percentage
of
Ownership
Title
8. Is this company DBE Certified? YES NO MBE Certified? YES NO EDGE Certified? YES NO
9. Name of person(s) responsible for day-to-day operation of business. _______________________________________________________
10. Has this company ever conducted business under another name? YES NO
If yes, please state former names (s): _________________________________________________________________________________
11. Are you a U.S. citizen? YES NO If no, do you hold a valid green card? YES NO Please attach a copy of green card.
12. Please attach proof of ethnicity
(Copy Of Birth Certificate Certificate of Naturalization Driver’s Licenses Passport )
13. Please complete the Affidavit. Notarize it and return all information and attachments to ODI.
For Office use only:
Date Received:
Registration Expires: Registered By:
