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Lexington Minority and Women Business Training Program Application
Please fill out all requested information below. All information will be considered confidential and will be used to determine the
appropriate qualifications for the training program. Please print or type all information.
Name: ______________________________________________________________
Title: _______________________________________________________________
Name of Business: ____________________________________________________
Address of Business: __________________________________________________
Business Phone: ____________ Fax ____________ E-mail __________________
Business Description:
1. Please give a detailed description of the type of products and/or services your business
offers.
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
___________________________________________________________________
2. Are you certified as one of the following? 3. Indicate applicant’s ethnic group:
Y N (MBE) Minority Owned Business Enterprise Native American/Alaskan Native ______
Y N (WBE) Woman Owned Business Enterprise Asian ______ White ______
Y N (DBE) Disadvantage Business Enterprise Native Hawaiian/Pacific Islander ______
Y N (8 (a)) SBA 8 (a) Black/African American ______
4. Are you Hispanic? Y N 5. Gender: Male________ Female_______
6. Please list all owners and the percentage of the ownership in the business listed above:
Name______________________________________________________% of Ownership_______
Name______________________________________________________ % of Ownership_______
Name______________________________________________________% of Ownership_______
7. Number of employees 0 ___ 1-5 ___ 6-10 ___ 11-20 ___ 21-50 ___ 51 or more ___
8. When was the business established? ____________
9. Annual gross revenues for the previous three years? 2012_____2011______2010_____
10. What is your expected annual volume this year: $__________________
11. Do you have multiple locations? Yes____ No____

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GOALS
12. To help us in determining how we can best assist your business, we would like you
to describe your long and short-term goals for your company. Please rate the THREE
most important objectives of your company with one being the most important.
______ Increase Revenue ______ Increase Profitability
______ Secure Government Contracts ______ Increase Employee Retention
______ Improve Efficiency ______ Raise Overall Business Acumen
______ Increase Cash Flow ______ Do More Corporate Work
______ Grow Client Base ______ Have More Leisure Time
______ Secure a Business Loan Other_______________________________
Workshop Location: Fifth Third Bank
900 Beasley Street, 2nd
Floor
Lexington, KY 40509
Start Date & Time: Wednesday, September 25, 2013
9:00 am – 12:00 pm
Cost: $50.00 (Payable September 25, 2013; contingent on program acceptance)
APPLICATION DEADLINE: September11, 2013
All accepted applicants will be notified prior to the start of the training.
Mail, fax or e-mail your Application for Admission to the following:
Marilyn Clark
Minority Business Enterprise Liaison
LFUCG Division of Central Purchasing
200 East Main Street, Room 341
Lexington, KY 40507
(859) 258.3323
Fax: (859) 258-3322 E-mail: mclark@lexingtonky.gov
Dee Dee Harbut
Director of Special Programs
Kentucky Small Business Development Center
1 Quality Street, Suite 635
Lexington, KY 40507