Maine PTAC

**Client Registration Form**
* Required Fields
Company Information:
	Company Name Business Email Business Phone Business Fax Website	Street Address City State (Abbr) Zip Code *County
Point of Contact:
	First Name Last Name *Contacts Email (If same as "Business Email" leave blank)	Contact's Position
		*Contact's Phone
			Cell	Business
		(If same as "Business Phone" leave blank)


Company Details:
	Date Company Established No. of Full Time Employees No. of Part Time Employees Business Type International Trade	Type of Organization State of Incorporation Company Gender Ethnic Background Company Veteran Status
	*Business Size

Company Profile:

	Check if you currently have a Duns & Bradstreet (D-U-N-S) Number
	Check if you are currently registered in the Central Contractor Registry (CCR)
	Check if you have ever sold a product or service to a federal, state or municipal government agency
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		If you checked this option, please check if you are under contract at this time
	Check if you are or have ever been listed on the GSA schedule
	Check if you are or plan to market your product or service internationally (including Canada or Mexico under NAFTA)
*Describe your product or service (be as specific as possible)

*Does Your Company do Research and Development?

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If yes, in what area?

What is your desired geographic marketing area?

How were you referred to Maine PTAC

© 2005 Maine Procurement Technical Assistance Center
Bangor - 40 Harlow Street, Bangor, ME 04401 • Phone (207) 942-6389
Lewiston - 415 Lisbon Street, Suite 400, Lewiston ME 04240 • Phone: (207) 777-5067
Portland, Saco, Bath - 403 Hallowell Road, Pownal, Maine 04069 • Phone: (207) 653-8625
1-800-339-6389

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