Cox Communications Small Business Growth Academy Registration and Assessment Form

General Information

Business Name*

Business Owner's Name*

Business Address*

Business Phone Number*

Email Address*

Business Website Address*

Are you a current vendor of Cox Communications?

Yes

No

Are you a Cox Communications business customer?

Yes

No

Please select your service type.

Construction

Professional Services

Goods & Services

Please select your business structure.

Limited Liability Company

Corporation

S Corporation

Sole Proprietorship

Partnership

Cooperative

Please select the Parish(es) in which your business is domiciled. *

If other, please specify.

Capacity

Does your business have a Federal Tax ID Number?

Yes

No

If yes, please enter.

Is your business registered to do business in the State of Louisiana?

Yes

No

Does your business have an Occupational License?

Yes

No

Does your business employ more than three full-time employees?

Yes

No

Has your business successfully completed five or more contracts as a prime contractor or subcontractor?

Yes

No

Is your business bonded and/or insured?

Yes

No

Does your business follow a defined set of procedures in its strategic planning process?

Yes

No

Does your business have a written mission statement?

Yes

No

Does your business have written long-term and short-term goals?

Yes

No

Does your business decide its strategic plan(s) based on feasibility and risk/return criteria?

Yes

No

What are your current needs for business assistance?*

Areas of Leadership

Do you have a clear one, three, and five-year vision for your company?

Yes

No

Have you identified measurable goals that support your company's vision?

Yes

No

Certifications

Is your business certified as a State and Local Disadvantaged Business Enterprise (SLDBE)?

Yes

No

Is your business certified as a Disadvantaged Business Enterprise (DBE) minority business enterprise (MBE) through the Louisiana Unified Certification Program (LAUCP)?

Yes

No

Does your business hold any other certifications?

Yes

No

If yes, please list those certifications.

Header Two

Cox Communications Small Business Growth Academy Registration and Assessment Form