GNEMSDC Subscription Service

Subscription Services Application
Date*

MonthDayYear
Date
Email*
example@example.com
Company Name*
Addresss*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Website Address*
Contact Person*
Owner's Name*
Business Phone*
Please enter a valid phone number.
Fax
Please enter a valid phone number.
NMSDC Affiliate Council*
Certification Expiration Date*

MonthDayYear
Date
Annual Sales for Current Year*
Product/Service Description*
Geographical Market (Check applicable). List states which firm is capable of serving.*

LocalNationalRegionalInternational
List States
Ethnic/Gender Code: Please specify the ethnic origin of the person(s) who own and control the firm. *(Ethnicity group status determined on the basis of the minority definition in the NMSDC Guidelines)*

BLM Black American MaleBLF Black American FemaleHIM Hispanic American MaleHIF Hispanic American FemaleNAM Native American MaleNAF Native American FemaleAPM Asian-Pacific Amer. MaleAPF Asian-Pacific Amer. FemaleAIM Asian-Indian Amer. MaleAIF Asian-Indian Amer. Female
The undersigned swears that the foregoing statements are true and correct and include all information necesary to identify and explain the operations of as well as the ownership thereof. Further, the undersigned agrees to provide the non-refundable payment and any proposed changes, if any, and to permit the audit and examination of books, records, and files of the named firm.*
I am executing this affidavit, and state that I am properly authorized by(name of firm)* to execute the affidavit and I am doing so as a free act and deed.
First & Last Name*
Authorized Submitter*
Title*
Date*

MonthDayYear
Should be Empty: