Membership Form

Type of Membership:
Business Information
Name of Business:
Address:
City:
State:
Zip:
Telephone Number:	i.e. (202)555-1234
Fax Number:	i.e. (202)555-5678
Email Address:
Contact Name
Contact Title:
Contact Phone :	if different from above
NAICS Code(s) (SIC codes)
Congressional District
County Code	list of codes by state
Certifications:
** If other, please explain:
Type of Business:
** If other, please explain:
Business Ownership Status:
Location of Business:
Size of Business:
Annual Gross:	$
The number of employees over the last 5 years?:	Increased Decreased Same
By what percent?:
If the number of employees has decreased, please explain:
Number of Tribal members currently employed:
Number of other American Indian or Alaska Native non-Tribal members employed:
What are the business's major products or services?
Brief description of your business and it's products and services:
List in NIBA's business directory?:	Yes, please list me in the directory No, do not list me in the directory

NIBA Membership Enrollment & Survey