PSWMSDC CORPORATE MEMBERSHIP APPLICATION

CORPORATE MEMBERSHIP APPLICATION
Please answer all questions as completely as possible. If a particular question does not apply to your business operation, write N/A in space provided.
Name

First NameLast Name
Company
Contact

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Website
FEIN #
Dun & Bradstreet #
Parent Company
Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
# of Employees
Year Business Established
Year Supplier Diversity Department Established
List of top three executives and their titles
Name

First NameLast Name
Title
Name

First NameLast Name
Title
Name

First NameLast Name
Title
In the space provided, please give a concise description of your company's product(s) and service(s). If your company offers more than one product/service, list primary product/service first. Use additional paper if necessary and attach to this form
Please list your earnings for the last two years, if less than one year, please provide year-to-date earnings
Year Ending
Earnings
Year Ending
Earnings
What was your MBE spend for the past two years? If less than one year, please provide
Year Ending
MBE Spend
Year Ending
MBE Spend
How did you hear about PSWMSDC?

Event or PresentationCorporate MembersSocial MediaOther
Please provide one current customer and two MBE references
Company (Customer)
Name

First NameLast Name
Title
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Company (MBE #1)
Name

First NameLast Name
Title
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Product/Service
Spend with MBE last year
Company (MBE #2)
Name

First NameLast Name
Title
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Email
example@example.com
Product/Service
Payment Information
How will you be paying for your membership? Note: An invoice will be forwarded to you.
Thank you for your interest in Pacific Southwest Minority Supplier Development Council. Please email president@pswmsdc.org if you have any questions. Otherwise, please submit your form and we will reach out to you within 24 hours.
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CORPORATE MEMBERSHIP APPLICATION

Payment Information