Name:
Title:
Organization:
Street Address:
2nd Street Address:
City:
State/Province:
Zip/Postal Code:
Country:
Phone:
FAX:
E-mail:
URL:
	Type of Business or Profession.
	Please Describe your business.
	What is your Tribal Affiliation (of individual)?
	Is your company certified as MWBE?: yes no
	Please list all agencies with whom you are certified.
	What Membership Classification fits you best? 1 - 7 Employess .... $100.00 8 - 24 Employees .... $250.00 25 - 49 Employees .... $300.00 50 - 74 Employees .... $500.00 75+ Employees .... $750.00 Individual Membership .... $35.00 Non-Profit Organization .... $100.00 Corporate Membership .... $1,500.00

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