MBE Subscription Services Application

MBE Subscription Services Application

Thank you for your interest in subscription services with the NYNJ Minority Supplier Development Council (NYNJMSDC).
IMPORTANT

Name of NMSDC Affiliate Council where company obtained original certification and expiration date:
Home Council*
Expiration Date*

MonthDayYear
Date
Company Name*
DBA (if applicable)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Office Phone*
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Email*
example@example.com
Website
Tax ID Number*
Owner Name*

First NameLast Name
Owner Title*
Owner Email*
example@example.com
Owner Phone Number*
Please enter a valid phone number.
Please give a concise description of the company’s products or services as documented by your home council. The description below will be placed in our database and online directory.*
NAICS Codes (please separate by commas)*
Annual Sales*
AFFIDAVIT

The undersigned swears that the foregoing statements are true and correct and include all material information necessary to identify and explain the operations of Type a label ,
as well as the ownership thereof. Further, the undersigned agrees to provide current, complete and accurate information regarding actual work performed on a project, the payment therefore and any proposed changes, if any, of the foregoing arrangements 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 to execute the affidavit and am doing so as a free act and deed.

Furthermore, I understand that:

The NY & NJ Minority Supplier Development Council reserves the right to request any additional information that it may deem necessary to substantiate the information and representations made by the applicant(s) for subscription services.

The undersigned hereby declares under penalty of perjury that all statements made in this application and any attachments hereto are true and correct. I understand that the Subscription Services Application Fee is included and non-refundable.

Signature of all Proprietor, Partners and President of the Corporation
Signature*

Clear
Date*

MonthDayYear
Date
Signature

Clear
Date

MonthDayYear
Date
Signature

Clear
Date

MonthDayYear
Date
Signature

Clear
Date

MonthDayYear
Date
Signature

Clear
Date

MonthDayYear
Date
Signature

Clear
Date

MonthDayYear
Date
Please allow ten (10) business days for processing.
Please retain a copy of this form for your files.
Method of Payment*

Invoiced to Pay by CheckCredit Card
Please Select Subscription Level*

Class 1 - Sales Under $1 Million ($350.00)Class 2 - Sales $1 Million - $10 Million ($550.00)Class 3 - Sales $10 Million - $50 Million ($900.00)Class 4 - Sales over $50 Million ($1,000.00)
Total Amount Due*
My Products
prevnext( X )
Subscription: Class 1Sales Under $1 Million
$350.00



Subscription: Class 2Sales $1 Million - $10 Million
$550.00



Subscription: Class 3Sales $10 Million - $50 Million
$900.00



Subscription: Class 4Sales over $50 Million
$1,000.00



Total

$0.00

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

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