On-Line Client Information Form

Instructions

After reading these instructions, click on the button below to return to the Client Information Form. If you have any questions please contact us at . Thank you.

CLICK HERE TO RETURN TO THE CLIENT INFORMATION FORM

Field Name	Information to Enter
Contact Name	Enter the person that will be communicating with us
Business Owners	Enter Business Owners
Company Legal Business Name	Enter Legal Business Name
Company Registered as a DBA or Fictitious Name?	In Missouri, anyone who owns and operates a business with a name other than his or her own legal name must register that "fictitious name" with the Secretary of State s office. Kansas does not list or register DBAs because Kansas does not have a statute requiring or permitting the registration or filing of DBAs or fictitious names. Be sure to check with the appropriate office State office if you don't know.
Business Address	Enter Street Name/Number, City, State, and Zip
Mailing Address	Enter Mailing Address if different than Business Address
County	Enter the County where business is located
Work Telephone	Enter Telephone Number of Contact Name
Work Email	This is the email address we will use for bid-matching service and to communicate by email with you
Web Address	Enter company Web Address if you have one
Federal Congressional District	Select Congressional District if known
Approximate Date Business Started	Enter the month-day-year that business started, e.g., 01-02-1956
DUNS Number	Enter DUNS Number-if you don't have or don't know leave blank and we will assist you with getting a number
Fiscal Year Ends	Enter month-day when Fiscal Year ends (usually January 1st, enter as 01-01, or December 31, enter as 12-31)
Number of Employees	Enter the average number of full-time and part-time employees
Ownership Type	Select business structure
Business Type	Select the category that best identifies your business
Business Size/Designation	Select Business Size/Designation if known
Incorporated	Select "Yes" or "No", If "Yes" enter State where incorporated
Business Owner's Military Status	Enter Military Status of Majority business owner
Owner's Ethnic Group	Enter Ethnic Group of Majority business owner
Owner's Gender	Enter Gender of Majority business owner
Describe Business	Describe what what your business does
NAICs Codes	Enter these codes for your product/service if known
FSC/PSC Codes	Enter these codes for your product/service if known
SIC Codes	Enter these codes for your product/service if known
Referral From	Enter how you found out about Heartland PTAC
Current Business Status	Enter the "health" of your business
Company Parent/Affiliate	Select "Yes" or "No" and name if company has corporate or affiliate offices
Other Office to Submit Quotes	Select "Yes" or "No" if there is another office that submits government contracting quotes/proposals
Government Contracting Office	Select "Yes" or "No" if your company has a separate Government Contracting Office
Any Contracting Experience	Select "Yes" or "No" if company has any government contracting experience
Special Security Clearances	Select "Yes" or "No"
Quality Standard Designations	Select "Yes" or "No" , list if "Yes" is selected
Other Locations	Select "Yes" or "No" if there are other physical locations for your company
Where you want to Market	Select what geographical area you want to market
Accept Credit Cards	Select "Yes" or "No"
Your Name	After reading "Certification", Enter Your Name
Your Email	Enter Your Email Address