The intent of this survey is to collect contact information on minority-owned businesses and contractors in the Gulf Coast area, especially those operating and wanting to do business in Escambia County, Florida. 

*1.CONTACT INFORMATION:
Information provided in these cells will appear in business listing.(Required.)

Business Name:

Owner First & Last Name:

Title:

Business Primary Phone Number:

Business Primary Email Address:

Business Official Website:

Business Official Facebook Page:

Full Business Address:
Include street number, street, suite {if applicable}, city, state and zip code. 

*2.PERSON COMPLETING THIS FORM: (If different than above)
This information is for contact and confirmation purposes only. It will not appear in the listing.  If same as above, enter SAME in cell #1(Required.)

First & Last Name:

Title:

Phone:

Email Address:

Are you an authorized employee of this business?

*3.NATURE OF BUSINESS SERVICES/PRODUCTS:
Select up to five (5). Feel free to specify speciality services/products in the OTHER option.(Required.)

Architectural/Custodial

Arts/Culture/Entertainment/Event Planning/Photography

Beauty & Fashion

Business Development

Churches/Places of Worship

Computer Technology

Custodial/Environmental Remediation

Medical/Dental

Education

Financial/Insurance

Food & Beverage

Funeral/Memorial Services

Home & Garden

Health & Fitness

Legal

Media/Marketing/Advertising

Non-Profit Organization

Real Estate

Support for Women

Transportation

Other (please specify)

*4.SELECT ALL CATEGORIES THAT ACCURATELY DESCRIBE SAID BUSINESS:(Required.)

Florida State Division of Corporations-Registered Business

Minority Owned Business (51% owned and operated)

Minority Owned Enterprise (51% owned and operated)

Small Disadvantaged Business (SDB)

Black Owned Business (51% owned and operated)

Asian/Pacific Islander Owned Business (51% owned and operated)

Latin/Hispanic Owned Business (51% owned and operated)

Native American Owned Business (51% owned and operated)

Women Owned Business (51% owned and operated)

SBA Women Owned Small Business Certified (WOSB)

Veteran Owned Business (51% owned and operated)

Certified Veteran Owned Business (VOB)

Certified Disability Owned Business Enterprise (DOBE)
Including Veteran and Service Disabled Veteran businesses.

Escambia County Registered Vendor

City of Pensacola Registered Vendor

HubZone SBA 8A Business

USBR Federally Certified Small Business

Other (please specify)

*5.LICENSES/CERTIFICATIONS RELEVANT TO BUSINESS SERVICES AND PRODUCTS:
Provide full name of license/certification and issuing entity. If not applicable, enter N/A in Cell #1. (Required.)

1.

2.

3.

4.

5.

*6.AWARDS/RECOGNITION FOR BUSINESS SERVICES AND PRODUCTS:
Provide full name of awards/recognition and issuing entity. If not applicable, enter N/A in Cell #1. (Required.)

1.

2.

3.

4.

5.

*7.SERVICE AREA:
Select counties where this business can and will provide services.(Required.)

Escambia County, FL 

Escambia County, AL

Santa Rosa County, FL

Okaloosa County, FL

Walton County, FL

Jefferson County, AL

Other (please specify)

None of the above

By submitting this form you are requesting to have your business and its contact information added to the Escambia County Minority Owned Businesses & Contractors List, a project of Gulf Coast Minority Chamber of Commerce (GCMCC), Escambia County, Florida, the City of Pensacola Office Supplier of Diversity and Bantucola. Submission of  this form means you attest all information provided is up to date and accurate, the business is 51% minority and/or women owned and operated and grant the curator permission to publish all information provided. 

Thank you for your submission.
Please direct any questions, comments or concerns to (850) 438-3993 or info@gcmcc.info.