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:
*ZIP Code:
Physical address is home office

Mailing Address: Same as Physical Address
Address Line 1:
Address Line 2:
ZIP Code:
*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.


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 Role Ownership