HMSDC Forms

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Date of Application

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Company

Parent Company, if applicable

Company Address

Street Address

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City

State

Zip Code

Mailing Address (if different)

Street Address

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City

State

Zip Code

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Company Telephone

Company Fax Number

Company Website

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Industry

Ethnicity

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Owner's Name

Owner's Email Address

example@example.com

Secondary Contact Name

Secondary Contact Email Address

example@example.com

Owner's Title

Owner's Phone Number

Please enter a valid phone number.

Secondary Contact Title

Secondary Contact Phone Number

In the space below, please give a concise description of company’s product(s), service(s), or type of construction. If your company offers more than one product/service, list primary product or service first. Use additional paper, if necessary, and attach to this form. The description below will be placed in our database and online directory.

NAICS code(s) separated by commas

Date Business was Established

What are the gross receipts of your firm for each of the past four years? (if in business less than one year, provide gross receipts to date)

2024 Gross Sales to Date (Only If Business Started this Year)

2023 Gross Sales

2022 Gross Sales

2021 Gross Sales

2020 Gross Sales

Number of Employees

Full-Time

Part-Time

Number of Minority Employees

Type of Business (check primary function)

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*NMSDC’s definition of Sole Proprietorship is a company owned/operated 100% by one (1) individual or married couple. Split ownership does not constitute Sole Proprietorship.

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What is your home NMSDC affiliate council?

Expiration Date

Please list each owner, proprietor, partner, officer, member, director and stockholder. The name listed should include minority group members and non-minority group members. NMSDC does not certify non-citizens. Please put ‘N/A’ in all unused fields.

Owner 1

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Name/Title

Years of Ownership

Ethnic Origin*

Ownership Role

Gender

Ownership Percentage

Citizenship

Voting %

Owner 2

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Name/Title

Years of Ownership

Ethnic Origin*

Ownership Role

Gender

Ownership Percentage

Citizenship

Voting %

Owner 3

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Name/Title

Years of Ownership

Ethnic Origin*

Ownership Role

Gender

Ownership Percentage

Citizenship

Voting %

Please upload a copy of your certificate

Click or drag files to this area to upload. You can upload up to 100 files.

Fee Structure

Class 1 ($0 – $1M)

$450

Class 2 ($1M – $10M)

$600

Class 3 ($10 – $50M)

$800

Class 4 ($50M+)

$1,000

Signature of all Proprietors, Partners, and President of the Company

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Signature

Click or drag a file to this area to upload.

Date

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Signature

Click or drag a file to this area to upload.

Date

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Signature

Click or drag a file to this area to upload.

Date

Subscription Services Application