PROBID Subscription Form

Contact Person _________________________________________________________

Company _________________________________________________________

Address _________________________________________________________

City/State/ZIP __________________________________________________________

Telephone ________________________ FAX _______________________

e-mail __________________________________________________________

Circle all that apply: Small Large Corporation Partnership Retail

Proprietorship Manufacturing Construction Service Wholesale

Minority-owned Woman-owned Male-owned Male/female-owned

Veteran-owned

Date founded _______ Number of employees _______ Annual sales $________

Please attach product or service information.

PAYMENT

Please make your check for $275.00 for a 12-month subscription payable to the SBTDC and mail to or provide the information below for a credit card charge. Mail to: SBTDC/PTAC – PROBID, 5 West Hargett Street, Suite 600, Raleigh, NC 27601-1348. Credit card charges can be FAXed to 919/715-7777.

Name (as it appears on card): ________________________________________________

Please charge my: VISA Master Card

Card Number___________________________________Expiration date: _____________

Signature:____________________________________________________________

NOTE: Statement will list payment to "NCSU SBTDC INT."