Asian American Owned Business Member Registration

Company Name:
Owner Name:
Contact Name:
Contact Title:
PO Box:
Street:
City:
State:
Zip:
Company Phone Number: (XXX)XXX-XXXX   Ext.
Company Fax Number: (XXX)XXX-XXXX
Contact E-Mail Address:
Company Website (URL):
Federal ID Number:   (SSN if Sole Proprietorship)
DUN and Bradstreet Number:
Year Established:
Company Structure:
Geographical Service Area:
Select all that apply.
Select NAICS Code(s)
To remove items from the list above, highlight the NAICS code and click Remove From List button.
Product/Service Description: (up to 500 characters)
Online Catalog (URL):
Asian Origin:
Owner Gender:
Certification Type:
           
Certifying Organization:
Certification No.:
Expiration Date:   (MM/DD/YYYY)
Revenue Year:
Annual Revenue:
List current business customer (local or otherwise) which have been or are now your customers:
Company Name Contact Name Phone Number
(XXX)XXX-XXXX		 Email
Membership Fee:
Membership Payment Method:
Credit Card Number:
Expiration Date:  
3-digit Authorization Number (back of card)
 
Mail To Address:
Please mail a check with the amount indicated above to:

USPAACC-SE
6292 Lawrenceville Hwy
Tucker, GA 30084. U.S.A.
Fax: 770-989-3316

 
By choosing to submit this form, you certify that the information you have provided above is true and accurate.