APPLICATION INSTRUCTIONS:   
1.   From the Sheet with a Listing of Directory Cities, select and write in the City in which the Business is to be listed.  If the City is not listed, choose the City nearest to it;

2.   From the Sheet with a Listing of Business Categories, select and write in the Business Category most representing the Business.  If none is representative, choose the "Professional, General" Category;

3.   Check the box for Business Preference, which represents the Business;

4.    Write in the Standard Industry Codes (SIC) if one refers to your business, enter up to four.  If you do not know the SIC, you may wait until you are inputting the Listing and click the link to go to a special website to lookup SIC codes.  Click "BACK" to return to the form;

5.   Complete this form by printing with  black or blue ink; and

6.   Go online to the African American Business Directory at "www.AfricanAmericaBusiness.com" and click on the "Listing Submission Form" link to input this Listing .

Please Enter the Directory City (Name):  ________________________ 

                and Business Category (Name):  ________________________

Please Select the Business Preference: 
[  ] Not Applicable                                                                  [  ] Woman / Female Owned    
[  ] Business Owner with a Qualified Physical Disability     [  ] Business Owner with Veterans Preference 

Enter Up To Four Business Standard Industry Codes (SIC), If Applicable:
   SIC 1:_____  SIC 2:_____   SIC 3:_____   SIC 4:_____ 

Please enter information as you wish to have it presented in the Directory:

Name Of Your Business: ________________________________________________________________

Federal ID No. or Social Security No.:   ___________________________
   (Federal ID or Social Security information is not displayed, it is for business identification only.)

Enter The Unique Specialty of your business: (200 Characters or less, including spaces)
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

Address Line 1:  ______________________________________________

Address Line 2:  ______________________________________

City:  ________________________   State: ______  Zip+ 4 (zzzzz-xxxx):    ____________________

Contact Person:  ___________________________________________

Business Phone No. w/Area Code (xxx-xxx-xxxx):    __________________Extension:  ________     

Fax (xxx-xxx-xxxx):  __________________

E-Mail Address (if available):   ____________________________________________

Web Site Address (if available):  ____________________________________________

Simplest Directions From Nearest Major Thoroughfare:  (200 Characters or less, including spaces)
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

RESPONSIBLE PARTY INFORMATION (For Business Purpose only, will not be in Directory) :

First Name/Initial:  ________________________Last Name:  _____________________________

Mailing Address, Line 1:    _________________________Line 2:   ________________________

City:  ________________________       State:  _______Zip+4 (zzzzz-xxxx):   ___________________

Telephone No. w/Area Code (xxx-xxx-xxxx):    ____________________