NEBGC 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.Format: (000) 000-0000.
Fax
Please enter a valid phone number.Format: (000) 000-0000.
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.
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)
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: