Please enter the following information The question marked with an '*' are required fields. If you have any questions on any of the other fields, do not hesitate to leave the field blank and your CIRAS PTAP specialist will assist you after submitting the form. Business Name (DBA)* PhoneEmail* Contact Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Title Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code CountyAdairAdamsAllamakeeAppanooseAudubonBentonBlack HawkBooneBremerBuchananBuena VistaButlerCalhounCarrollCassCedarCerro GordoCherokeeChickasawClarkeClayClaytonClintonCrawfordDallasDavisDecaturDelawareDes MoinesDickinsonDubuqueEmmetFayetteFloydFranklinFremontGreeneGrundyGuthrieHamiltonHancockHardinHarrisonHenryHowardHumboldtIdaIowaJacksonJasperJeffersonJohnsonJonesKeokukKossuthLeeLinnLouisaLucasLyonMadisonMahaskaMarionMarshallMillsMitchellMononaMonroeMontgomeryMuscatineO'BrienOsceolaPagePalo AltoPlymouthPocahontasPolkPottawattamiePoweshiekRinggoldSacScottShelbySiouxStoryTamaTaylorUnionVan BurenWapelloWarrenWashingtonWayneWebsterWinnebagoWinneshiekWoodburyWorthWrightDUNS Number CAGE Code Website NAICS Code Number of Employees Business Classification(s): Small Business Women Owned Small Business HUB Zone Business Small Disadvantaged Business SBA 8(a) Veteran Owned Service Disabled Veteran Owned Business Iowa Targeted Small Business(TSB) DOT Disadvantaged Business Enterprise(DBE) (Large Business or Non-profit) Other than Small Business I request counseling assistance from Iowa State University CIRAS-Procurement Technical Assistance Program (PTAP). I understand and agree to participate in and return requested quarterly surveys within 7 days of request as they are designed to evaluate the Procurement Assistance services. As a client, I realize that I will occasionally receive notices, announcements, and marketing materials designed to inform and assist me. I further understand that all CIRAS-Procurement Assistance personnel cannot: 1. Recommend goods or services from sources in which they have an interest, 2. Accept fees or commissions developing from this counseling relationship. By my signature below, and in consideration of CIRAS-Procuerement Assistance furnishing of procurement, management or technical assistance, I waive all claims against Iowa State University, CIRAS-Procurement Assistance personnel and its host organization(s). I understand that there are no warranties or assurance in connection with the counseling assistance. This agreement must be executed by an authorized official of the Client company or organization. Printed Name* Date* MM slash DD slash YYYY How did you hear about CIRAS?* CIRAS personal contact (phone, visit, etc) Colleague/Reference Email Linkedln Twitter Facebook CIRAS News CIRAS Website Other, please specify If you selected other above, please specify: Twitter handle PhoneThis field is for validation purposes and should be left unchanged.