Business Directory Application

Company submitting application must be at least fifty-one percent (51%) owned,
operated and controlled by a Chickasaw citizen(s).

Once your application is received, you will be contacted and asked to provide supporting
documentation, including a copy of your Certificate of Degree of Indian Blood (CDIB) card
and proof of business ownership.

Thank you for listing your business on the Chickasaw Business Directory!

*Fields marked with an asterisk are required.

*Company Name:
Parent Company:
 
 
Physical Address
*Address Line 1:
Address Line 2:
*City:
*State:
*ZIP Code:
Physical address is home office

 
 
Mailing Address: Same as Physical Address
Address Line 1:
Address Line 2:
City:
State:
ZIP Code:
 
 
*Phone:
Fax:
Website:
*Email:
*Key Contact(s) Name:
*Key Contact's Title:
Employer's Federal Tax ID#:
(numbers only, no dashes)
SSN (for Indv Only):
(numbers only, no dashes)
*Primary Classification:
*Geographical Market:
*Type of Legal Business Structure:
 

 

Please check any certifications that your company holds:
8(a) Certification Minority(MBE) Hubzone
SDB Certification Woman Owned (WBE) Disabled Veteran (DVBE)
National Minority Supplier Development Council


Please give a concise description of your company products, services, or type of construction. If your
company offers more than one product or service, list primary products or service first.

*Description:


*Owners/Stakeholder
Please list each owner, proprietor, partner, officer, member, director and stockholder. The name listed should include Minority Group Members and Non-Minority Group Members.

  Name Title Gender Years of
Ownership
Ownership Role Ownership
Percentage
Voting
Percentage
*