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Vendor Opportunities Signup
Primary Contact
First Name:
Middle Initial:
Last Name:
Title:
Phone: ( ) Ext:
Fax: ( )
Email:
Secondary Contact
First Name:
Middle Initial:
Last Name:
Title:
Phone: ( ) Ext:
Fax: ( )
Email:
Business
Business Name:
Address Line 1:
Address Line 2:
City:
State / Province:
Zip / Postal Code:
Country:
Phone: ( )
Fax: ( )
Mailing Address
Same As Above:
Address Line 1:
Address Line 2:
City:
State / Province:
Zip / Postal Code:
Country:
Business Details
Legal Name:
Website URL:
Tax ID#:
Business Started: (MM/YYYY)
Number of Employees:
Corporate Status:


State Incorporated in:
Stock Symbol: Exchange:
Nature of the Business:
Products and Services
Check all that apply:
General product / service
description:
What differentiates your
company from your
competitors?
North American Industry
Classification System
(NAICS) Code(s):
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4.
5.
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7.
8.
9.
Is your corporation
currently a member
of any of the following
organizations?
Check all that apply:
Is your company a
Native-American
owned business?

The person submitting this form (i) declares to be authorized to act on behalf of the business and submit this form on behalf of the business, (ii) certifies that the information provided in this form is current, accurate and complete as of the date of this submission, and (iii) acknowledges that Match-E-Be-Nash-She-Wish Band of Pottawatomi Indians (Gun Lake Tribe) will be relying on this information.