Corporate Partners Program Participation Form

• Business Information:

  Contact Name
  Business Name
  Street Address
  Address (cont.)
  City
  State/Province
  Zip/Postal Code
  Country
  Work Phone
  FAX
  E-mail
  URL

• Type of Business (Circle All that Apply)

  High Tech               Manufacturing           Agriculture             Livestock             
  Insurance               Transportation          Forestry                Tourism               
  Construction            Finance                 Real Estate             Public Utilities      
  Gaming                  Research & Development  Natural Resources       Wholesale Trade       
  Fisheries               Service/Retail          Other                   

• If you checked "other" Please explain:

  
  

• What are your business' major products or services

  
  

• Is your Business owned by a woman?

  Yes No
  

• Are you a member of NIBA?

  Yes No
  

• Would you like to be listed in NIBA's database of businesses?

  Yes No
  

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Copyright � 2002 [The National Indian Business Association]. All rights reserved.
Revised: 05/12/05