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Thank you for your interest in our program's services. Please select a center nearest to your location and a representative will contact you shortly upon completion of this form.
Please select your nearest center
All mandatory fields appear in bold.
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Home Phone: Work Phone:
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Yes, I would like to be included in future center mailings.
Please complete the following fields so that we may better serve you in the future. All information provided here will remain confidential.
Gender: Race:
Hispanic: Veteran:
Reservist: Disabled:
Company Status: Business Type:
Briefly describe your current or proposed company's products/services:

Please complete the following details about your company.
Company Name: Date Established:
Organization Type:
Company Gender: Company Veteran Status:
Full-Time Employees: Part-Time Employees:
Business Online? Home-based Business?
Company Web Site:
Referral From: Assistance Requested:      
Please describe specific assistance requested:
As a client receiving assistance from the Procurement Technical Assistance Center, I agree to cooperate should I be selected to participate in surveys designed to evaluate the Procurement Technical Assistance Center's services. As a client receiving assistance, counseling, and information from the Procurement Technical Assistance Center, I agree to provide the PTAC with government prime and sub-contract award information each quarter. I hereby acknowledge that the Procurement Technical Assistance Center offers only general guidance on bidding opportunities and will not be responsible in any way for the outcome of attempts by the undersigned to obtain government contracts or any other business or to resolve disputes, and cannot guarantee results of any kind. The Procurement Technical Assistance Center may also offer its clients the names of companies and/or individuals for potential business collaboration, but it does not make any representations regarding the capabilities or otherwise endorse such companies and/or individuals. I understand that there are no warranties or assurances in connection with the counseling assistance.
Please provide your full name (First, Middle, Last) indicating your acceptance to the terms shown above.
Date: