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UAB Academic and Small Business Alliance Program Business Application

Company Name:(*)

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President/CEO(*)

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Primary Contact Person:(*)

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Email Address:(*)

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Telephone Number:(*)

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Website URL:

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Facebook

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Twitter

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Instagram

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Other social media (service and username):

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Describe products and services offered:

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# of Direct Employees

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# of Indirect Employees

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Select Business Type:

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Ethnicity of Business Owner(s)

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Revenue for the Past Two Years (not the current year)

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Add 2 Primary NAICS/SIC Code(s):

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Insurance

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Upload Insurance Proof (PDF preferred)

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Upload Business Status Documentation

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Upload Intern job description form

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Please add Three Business References

Business Reference 1 (Name, Address, Phone Number)

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Business Reference 2 (Name, Address, Phone Number)

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Business Reference 3 (Name, Address, Phone Number)

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I, attest that the information in this application is accurate and true to the best of my knowledge: Enter your Initials to confirm:(*)

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UAB Academic and Small Business Alliance Program Business Application