Contact Name
Company Name
Company Address
State & Zip Code
Billing Address if
Different
City, State & Zip Code
if different
Main phone number:
Your email address:
Categories you'd like
to be listed in. (You
can list in up to 5
categories per
listings). (Ex. Lawyer,
Attorney, Legal Advice,
litigation, etc.).
Special Comment or
phrase you'd like on
your listing that will be
given to each caller
(ex. We are a law
office that specializes
in Personal injury
By completing
&
signing this registration form (or submitting this e-mail
form) I confirm that at least 51% of my firm is owned by a
B
lack Person of
African Descent.
I declare that I can produce proof of 51% ownership
&
control by a black
person of African descent if required. (acceptable proof is usually
incorporation papers, Federal
/S
tate Minority business status, or signed
document
declaring ownership if required)
Cost of registration: $
1
00 per year
Payment option:
Electronic
Check
or
Credit Card or we can
e-mail invoice
using Pay Pal.
All Payments must be received before a registration form can be processed
Enter Date
Sign or Print Name
Here
