TAN Qualification Form

The Technical Assistance Network can provide your growing company with a broad array of services.  Qualification depends on our understanding your company and your needs.  The following information is required to assess your company and your needs.  All information is secure and confidential.  If you prefer, you can print the form, complete it manually and fax it to 985-448-4486, mail it to SLEC, P.O. Box 2048-NSU, Thibodaux, LA 70310 or drop it off in person to SLEC, 310 Ardoyne Drive, SLEC Building, Nicholls State University.

Company
First Name
Last Name
Title
Mailing Street
Mailing City
Mailing State
Mailing Zip
Phone
Mobile
Fax
Website
Social Security or Tax ID Number
Email
Parish
Year Business Established
Products and Services
Industry Sector
2007 Gross Revenue
2006 Gross Revenue
2005 Gross Revenue
2004 Gross Revenue
Is business 51% woman owned?
Is the business 51% minority owned?
If not yet in business, select one: