Name:

Business Name:

Business Address:
(Street. P.O. Box, City, State, Zip)

Email Address:   Website:

Type of Business:    Corporation         Sole Proprietorship            LLC

Number of Employees:       Days and hours of operation

Business Phone:       Cell Phone

Secondary Contact Person:

Telephone #:

Preferred method of contact: Business Phone    Cell Phone     E-mail

 What types of services would you like to see provided by this organization?

TYPE OF BUSINESS INDUSTRY: (please check below)

Accounting
Finance
Advertising
Retail
Trade/Imp./Exp
Restaurant/Bar		 Architect/Design
Legal
Service(specify)

Computer Technology
Nonprofit/Education
 Construction
Wholesale/Supply
Electrical
Printing/Copying
OTHER:
Real Estate/Property Mgmt

DEMOGRAPHICS: (for statistical profile only)

Catagory:
Black        White
Indian        Asian
Hispanic		  Sex: malefemale
Education Level:
No. of Years In Business
Certified MBE/WBE

ANNUAL FEE SCHEDULE:

Individual -- $25.00
Sole Proprietorships -- $50.00
Corporations, Associations, Organizations -- $100.00

The North East Business Association shall:
*Encourage better relationships between businesses and the consumer
*Seek more efficient methods of rendering service to consumers and other member businesses
*Promote and encourage business development
*Enhance individual member business firms through personal improvement
*Provide educational and support services to members
*Encourage trade with member firms
*Provide a forum for entrepreneurial training
*Provide opportunities for youth development within the business community
*Encourage positive relationships between employers and employee.

Complete application, print and mail with payment to:
North East Business Association, Inc.
P.O. Bow 171193
Kansas City, Kansas 66117-0193
Phone: (913) 909-7796 

Would you consider serving on the Board of Directors if asked? YES      NO

Do you own your business? YES NO
New Business Business Renewal (please XXX one)

(All information collected on this form is strictly confidential and will not be shared with any other source without written permission of the business owner)