Black Contractors Association of Kansas City Kansas, Inc.

A Kansas Nonprofit Corporation

*Required Field

*Business Name______________________________________________________

*Business Address____________________________________________________

*City___________________________________ *State_______ *Zip_____________

*Contact Name__________________________________ *Title_________________

Email____________________________ Web Address_______________________

*Phone Number___________________________ Fax________________________

*Years in Existence_______ *Referred By___________________________________

*Business Type: [ ]Sole Proprietor [ ] Corporation/LLC [ ] Nonprofit

*Business Description: (2-3 Sentences) Attach Any Additional Material

(business cards, pamphlets, brochures)

__________________________________________________________________

The above information will appear in our online directory for one year.

How did you hear about us? (Check One) *Method of Payment (Check One)

[ ] Word of mouth [ ] Email [ ] Check/Money Order Enclosed

[ ] A BCA-KCK Member [ ] A Friend [ ] Cash: In Person Only

[ ] Print Media [ ] Other [ ] Certified Check

___________________ [ ] Online: __________________

*Signature___________________________________ Date_____/_____/_________

Please Mail Form and Payment of $50.00 To:

Black Contractors Association of KCK, Inc.

2901 Parkwood Blvd.

Kansas City, KS 66104

(913) 206-1472

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Internal Use Only: [ ] Information mailed [ ] Follow-up Call made INIT_____

*Support Services Needed: ______________________________________________