Service Provider Application

Note:  Data entered into this form is not stored and cannot be edited, saved, or retrieved.  We suggest you copy the form to a Word document, fill in the information in Word, then copy and paste the information into this form. 

Please provide all of the following information:   * Required

* Type of organization

       For profit organization        Not-For-Profit organization

Contact Information

 * First Name:      MI:      * Last Name:
Title:  
* Email:  
* Telephone:      Ext:
Fax:  
* Organization:  
Address 1:  
Address 2:  
City:  
State:  
Zip code:  
* Website:  
 

For Profit Organization Only - Select Number of Employees:
1-20 employees 21-49 employees  50 or more employees
    $500 annual Fee      $1,000 annual Fee        $2,000 annual fee
 

Service Specialties (Limit of three)
Choose up to three service specialties and write a brief description of your organization's expertise for each of these specialties. (If your application is accepted, these descriptions will be included in your profile on the BizStarts Milwaukee web site.)
 
* Specialty 1
 
* Description of expertise (Limit to 50 words)
 
Specialty 2
 
Description of expertise (Limit to 50 words)
 
Specialty 3
 
Description of expertise (Limit to 50 words)
 
 

* Organization Overview
Please provide an overview of your organization. (Limit to 200 words). (If your application is accepted, this description will be included in your profile on the BizStarts Milwaukee web site.)
 
 

 Client References (Limit of three)
Please provide us with three client references and their contact information. (Please note your clients may be contacted by BizStarts Milwaukee staff. Their names will not be made available to anyone but BizStarts Milwaukee staff.)
 
Client Reference 1
 
* First Name:      MI:      * Last Name:
Title:  
* Email:  
* Telephone:      Ext:
Fax:  
* Organization:  
Address 1:  
Address 2:  
City:  
State:  
Zip code:  
Website:  
 
* Please provide a brief description of how your organization assisted this client. (Limit of 50 words)
 
 
 
 
Client Reference 2
 
 First Name:      MI:     Last Name:
Title:  
Email:  
Telephone:      Ext:
Fax:  
Organization:  
Address 1:  
Address 2:  
City:  
State:  
Zip code:  
Website:  
 
 Please provide a brief description of how your organization assisted this client. (Limit of 50 words)
 
 
 
 
Client Reference 3
 
 First Name:      MI:     Last Name:
Title:  
Email:  
Telephone:      Ext:
Fax:  
Organization:  
Address 1:  
Address 2:  
City:  
State:  
Zip code:  
Website:  
 
 Please provide a brief description of how your organization assisted this client. (Limit of 50 words)