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Corporate Membership Application
Company Information
Company*
Official Contact*

First NameLast Name
Title*
Address*

Street Address

Street Address Line 2

CityState / Province / Region

Zip / Postal CodeCountry
Phone Number*
Format: (000) 000-0000.
E-mail*
Website link for company supplier diversity or supplier page
Please include http://
Annual global sales for our corporation’s last fiscal year ($)*
Yes
Yes
I am interested in sponsorship
Billing Information
$3,700 (If your Annual Revenues are below $1 Billion)$5,500 (If your Annual Revenues are above $1 Billion)
Please send an invoiceCheck has been placed in mail
Check Number
Please make checks payable to Capital Region Minority Supplier Development Council.

Mail to:

Capital Region Minority Supplier Development Council
10901 Rhode Island Ave.
P.O. Box 1187
Beltsville, MD 20705
Alternate contact to the official contact
Name*

FirstLast
Title
Address

Street Address

Street Address Line 2

CityState / Province / Region

Zip / Postal CodeCountry
Phone Number
Format: (000) 000-0000.
E-mail*
Chief Procurement Officer
Name*

FirstLast
Title
Address

Street Address

Street Address Line 2

CityState / Province / Region

Zip / Postal CodeCountry
Phone Number
Format: (000) 000-0000.
E-mail*
Chief Executive Officer
Name*

FirstLast
Title
Address

Street Address

Street Address Line 2

CityState / Province / Region

Zip / Postal CodeCountry
Phone Number
Format: (000) 000-0000.
E-mail*
CAPTCHA*
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Corporate Membership Application