2. Department or Individual Submitting Request
4. Company
6. Company Address
8. City
9. State
10. Zip Code
12. Phone Number
13. Fax Number
15. Contact Person
16. Email Address
18. Federal Tax ID Number (Business)
19. Contractor License Number (if applicable)
21. Type of Organization

    1. Corporation
    2. Individual
    3. Partnership
    4. Other
22. If the type of organization is other, please explain.
24. Are you HUB certified?

    1. Yes
    2. No

    A Historically Underutilized Business (HUB) is a corporation, sole proprietorship, partnership or a joint venture formed for the purpose of making a profit in which at least 51 percent ownership of the business is by a woman, minority, and/or service-disabled veteran.

    
    

25. At least 51% ownership of the business is:

    1. Female
    2. Minority
    3. Service-disabled veteran
26. Would you like to be HUB certified?

    1. Yes
    2. No
28. Number of Employees (including owner)
32. Officers, Owners, or Partners
34. President
35. Vice President
37. Secretary
38. Treasurer
39. Owners/Partners
41. Type of Business

    1. Manufacturer
    2. Construction
    3. Registered Dealer
    4. Surplus Dealer

    1. Service Establishment
    2. Architect/Engineer
    3. Other
42. If the type of business is other, please explain.
44. Is business under a state contract?

    1. Yes
    2. No
45. If yes, state contract number:
47. Products and/or Services Offered (additional information may be attached)
48. Additional Resources
50. Indicate types of requests your company would like to be informed of (check all that apply)

    1. Low-value purchases (less than $500)
    2. Informal bids (less than $30,000)
    3. Formal bids ($30,000 and above)
    4. Construction projects
    5. Requests for proposals
51. Please upload a copy of your IRS Form W-9
53. If Printing and Returning by Mail:

    Please return this form and IRS Form W-9 to:
    
    Rowan County Human Resources
    Attn: Purchasing Department
    130 W Innes Street
    Salisbury, NC 28144

Leave This Blank:


55. 1. Receive an email copy of this form.
56. Email address

    This field is not part of the form submission.

57. Submit Submit and Print

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