The Central Virginia
Procurement Technical Assistance Center

A Member Of 
The Virginia Procurement Technical Assistance Program
At
George Mason University

Client Information

Instructions:

1. Fill out the Client Information form on-line.
2. At bottom of form, click the button "Next" to view the completed form.
3. At bottom of viewed form, click the button "PRINT" for a paper copy.
4. Fax the printed form to (434) 293-3694 or mail it with a company brochure to:

                       Central VA PTAC
                       2211 Hydraulic Road Suite 103
                       Charlottesville ,VA 22901-2705

If you have any questions , contact us at: Phone (434) 293-2136, Fax: (434)-293-3694, Email: cvptac@gmu.edu or visit our website: www.cvptac.org.

General Information
Tax ID Number: or
EIN:
DUNS Number:
CAGE Code:
Business Start Date:
Number of Employee's:
Annual Revenue$:
Type of Organization
Individual                   Partnership
Limited Liability         Non-Profit
Corporation-Incorporated in the state of

Business Size (Check one)
Small Business
Other Than Small Business
Type of Ownership (Check all that apply)
Veteran -If Service disabled, check here
Minority
Woman
Other - If Other, List here
Certifications (Check all that apply)
8a                  SDB
Hub Zone       ISO/SEI/CMM

 - Term Definitions -

Provide a brief description of your business:
Have you registered in the CCR? more information

List SIC codes applicable to your business: more information

List NAICS codes applicable to your business: more information

List PSC or FSC codes applicable to your business: more information

Check the one category that best describes your business:
IT Products                              IT Services
Architecture/Engineering              Construction
Maintenance Services                  Management Consulting
Research and development          Manufacturing
Management Support Services      Publications
Communications                          Miscellaneous

How did you hear about PTAP?
SBA          Friend         Internet           Business Fair           Seminar
SBDC       Direct Mail   Other:

Please check all of the following services that are of interest to you:
Counseling                          Educational Seminars
Electronic Bid Matching       Marketing Assistance

Please read and sign the following:

I understand that materials provided through the Procurement Technical Assistance Program are obtained from independent, outside sources, and should be used as a reference only. PTAP makes no representation or warranty as to the completeness or accuracy of any material or information provided. I agree that PTAP is not responsible for any consequential or any other damages arising out of or in connection with the use of any such materials or information. In consideration of the furnishing of services and technical assistance, I waive any and all claims against PTAP or its staff arising in connection with this assistance.

I also understand that by participating in PTAP's services, my organization agrees to periodically (twice a year) provide information about contract awards that were received due to assistance from the PTAP program. I understand that this information will be used only for the government's evaluation of PTAP's effectiveness.

_____________________________              ______________________________
         Authorized Signature                                   Date

Print the name and title of the person to contact regarding contract award information:

Name:
Title: