Client Information Form

 


 

Client Information Form

To register as a client with Heartland PTAC please read, complete all information below, and hit the "Submit Form" button.  Heartland PTAC provides services to companies  in Southwest Missouri and the State of Kansas that have been in business for at least one year and have internet access. 

We do not charge for services except for bid-matching.  We provide bid-matching for a minimum of 6 months without charge. If you then decide to continue after 6 mths., the cost is $180/yr. See "services" for more information about bid-matching and other services.
After submitting this form,  please if we have not contacted you within 2 business days. Please feel free, however,  to contact us in the meantime if you have any questions.  We look forward to working with you.

 Click HERE for instructions on completing this form.
 Fields in BLUE are REQUIRED

Please complete all fields below then hit the "Submit Form" button to send the completed form on-line to Heartland PTAC.  To clear the form and start over hit the "Reset" button. 

                     

Contact Name       

Business Owners  

   
OR check this box if owner is "Contact Name" listed above 

Company Legal  
  Business Name  
 

Prior PTAC Client?
 
Are you now or have you ever received services from another      Procurement Technical Assistance Center (PTAC)?
   Yes               No
   If Yes,  please give details (when, which PTAC Center, etc.)


 

Is Your Company   Registered as a DBA   or   Fictitious Name   (see instructions)   
  Yes      No

Business Address  
 Street Number/Name:   
 City:  State:  Zip:
Mailing Address   
(enter if different)   
 Street/PO Box: 
  City: State: Zip:

County   
   		   

Work Telephone  
(include area code)  
 		        Work Fax    

Work Email  
(email for us to   communicate with   your  company)  
  		        Web Address   

Federal   Congressional   District  (if known)  
  		       
  
Approximate  
    Date that Business   Started (mm-dd-yyyy)   
   --     DUNS Number  

Fiscal Year Ends   
(mm-dd)   
   		   -    Number Employees:  Full    Part

Ownership Type   
   		     Business Type  

  Business   
Size/Designation   
   		  

Incorporated ?   
   		         If Incorporated Select State 

Business Owner's   
Military Status    
   

Owner's Ethnic    Group   
  

Owner's Gender   
  		  
Describe What Your    Business Does     


Enter NAICs Codes   
   

  

Enter FSC/PSC    Codes   
  		 

Enter SIC Codes   
  		 

Referral From   
   
    
Current Business    Status   
 		  

Does your company have a parent or affiliate ?   Yes  No          
If "Yes" name the parent/affiliate:                          


Do you currently use another office to submit quotes? Yes  No


Does your company have a government contract administration office? Yes  No


Does your company have any government  contracting experience (local, State, or Federal)?  Yes No


Do any of your employees have special security clearances? Yes No 


Do you have any special quality standard designation? (ISO, etc.)?   Yes   No    
If "Yes" please list:


Does your company have any other production or service locations? Yes  No  


Where do you want to market your product or service?    


Does your company accept credit cards? Yes  No
Note: Most government agencies purchase with credit card (Visa).

Agreement of Understanding
 

By submitting this form I, the undersigned, certify that neither my company nor any of its officers appear on the Federal Government's Excluded Parties List.  I realize that no contracts or sales can be guaranteed from Heartland PTAC services and that Heartland PTAC services are not to be considered legal advice or counsel.  Completion of bids, offers, and pricing are the sole responsibility of my business/organization. 

Heartland PTAC makes no representation or warranty as to the completeness or accuracy of any material or information provided. I agree that Heartland PTAC, its host organizations, and resource partners are 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 Heartland PTAC and its staff.

I agree that my organization will report information requested by Heartland PTAC regarding contracts/subcontracts obtained as a result of assistance provided from Heartland PTAC (directly or indirectly). Reports include Monthly Client Status Report, surveys, and success stories needed by Heartland PTAC in accordance with the Department of Defense. I understand that information provided to Heartland PTAC will be held in strict confidence and only provided to the Department of  Defense as required and as appropriate to Congressional Offices to promote the program.

By submitting this form I understand and accept this Agreement.


 Your Name:   

Your Email: 


Thank you for completing the Client Information Form.  Hit  "Submit Form" below to send the form to us.
 

 
 
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 Copyright    [Heartland PTAC]. All rights reserved. Revised: February 29, 2008 (Dennis Fitzgerald)