Business Name*:

Business Address*:



City*:

State*:


Zip*:

Telephone number*:

Email:

*Contact Name:

*Title:

Needs and Interest Assessment:( I need or have an interest in the following area)
Business Networking Business Education Work Place/Space Operating Capital Grant Info. Non-Profit Status Tax Exempt Status Business Plan Marketing Plan Entreprenurship Financial Restructuring Government Contracts Employee Training Credit Improvement Business Coaching

Product Or Service:

Business Organization Type:

Corporation LLC Sole Proprietorship Parnership Other  

If Partnership, name Partners:

Membership Plan

$60-1-year Membership $100-2-Year Membership Other Service

I(We) hereby apply for membership in the (MBDG) Minority Business Development Group/Lagrange
Minority Business Network:

*Initial to indicate signature