Form 47228 - Application For Vendor Registration - State Of Indiana Page 3
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4____Check if this is a WOMAN OWNED BUSINESS.
Women Owned Business – A firm owned and controlled at least 51% by one or more females.
____Check if this is a DISADVATAGED OWNED BUSINESS.
Disadvantaged Owned Business – A business that is unconditionally owned and controlled by individual (s)
who are determined to be socially and economically disadvantaged by a recognized certifying authority.
If you checked Racial Minority Business or Women Owned Business, please check ethnic group that applies:
[ ] Black
[ ] Multi-racial
[ ] Hispanic
[ ] Asian Pacific
[ ] Native American
[ ] Asian Indian
[ ] Caucasian
[ ] Other (explain) ___________________________
[ ]
Check to indicate a SMALL BUSINESS as defined under 25 IAC 1.5-3-4 & IC 4-13-13.5-3
Small Business – As used in this clause means a business, which is independently, owned and operated,
not dominate in the field of operation and qualified as a small business under the following size
standards. If the business qualifies as a small business, please check the appropriate category and
include supporting documentation.
[ ]
Wholesale Business: Annual sales of four million dollars ($4,000,000) or less during its last fiscal
year. Provide most resent financial s statement. Wholesale business with annual sales of four million
dollars ($4,000,000) or less during its last fiscal year. “Wholesale business” means a business that
derives its principal source of income (over 50 percent of gross revenues) from sales to retailers, other
merchants, or industrial, institutional or commercial users who will use the goods for resale or
business use. This definition includes distribution activities. Please provide most recent certified
financial statement.
[ ]
Service Business: Average sales of five hundred thousand dollars ($5000,000) for the current and
preceding three (3) fiscal years and who employs no more than twenty-five (25) persons.
Service business with average sales of five hundred thousand dollars ($500,000) or less for the current
and preceding three (3) fiscal years and which employs no more than twenty-five (25) persons.
“Service business” means a business that derives its principal source of income (over 50 percent of
gross revenues) from the sale of useful artistic, educational, intellectual, literary, or scientific labor
from which no necessary tangible commodity is derived. Please provide most recent certified
financial statement and number of employee’s __________.
[ ]
Retail Business (business selling services): Annual sales and receipts of five hundred thousand dollars
($5000,000) or less. Retail business or business selling services with annual sales and receipts of five
hundred thousand dollars ($500,000) or less. “Retail business” means a business that derives its
principal source of income (over 50 percent of gross revenues) from the sale of supplies to the ultimate
consumer. Please provide most recent certified financial statement.
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