Saint Paul’s Baptist Church and Nia, Inc. of Greater Richmond

Stimulus Partnership Program

Survey Form

Business Information

Legal Business Name:

DBA/Trade Name (if different):

Federal Tax ID: (If you do not have one, please do not write in your SSN)

Registered and in good standing with Virginia State Corporation Commission?

• Yes

• No

Number of Years in Operation:

SWAM Certified?

• Yes

• No

DBE Certified?

• Yes

• No

Have you ever been awarded a state and/or federal contract? If so, when and for what?

Have you ever been placed on a debartment list? If so, when and why?

Business Mailing Address:

Physical Address, if different:

Website Address:

Type of Business:

• Construction

• Weatherization/Energy

• “Green” Industry

• Transportation (rail, air, ground)

• Broadband Technology

• Health Care & Social Assistance

• Grant Writing

• Capacity Building/Organizational Development

• Safety Training

• Other

Contact Person:

Title:

Business Phone Number:

Business Fax Number:

Business Email Address: