Small Business Fact Sheet

Small Businesses interested in working with Centurum should fill out the form below. If you have any questions regarding this information, please contact our Small Business Liaison.

General Infromation

Company Name:
Address:
City, State, Zip:
DUNS No.:
CAGE Code:
Web Address:
Contact Name:
Contact Phone:	- - Ext
Contact Fax:	- -
Contact Email:

History / Ownership

Give a brief overview of the history and/or ownership of the company:

Business Classification

Business Size:	Large Small
Business Type:	Manufacturer Distributor Service

Commodities / Services

List the specific commodities and/or services your company provides:

Specialized Expertise:

i.e.: machinery, equipment, materials, value added, etc.

Quality Assurance Standards:

ISO, etc.

Major Customers:

Have you previously done business with Centurum?

Yes No

If yes, please indicate date and Centurum location:

Small Business Data

Check all that apply:

	SBA certified small disadvantaged business (http://www.sba.gov) Certification Expiration Date:
	Non-certified small disadvantaged business
	Woman owned small business
	Veteran owned small business (http://vetbiz.gov/vip/vip.htm)
	Service disabled veteran owned small business
	SBA certified HUBZone supplier (http://eweb1.sba.gov/hubzone/internet) Certification Effective Date:
	HBCU/MI (historically black college/university or minority institution)
	Minority (specify: )
	Registered on CCR (Central Contractor Registry) and/or Dynamic Small Business Database (http://www.ccr.gov) (http://www.pro-net.sba.gov)