What City/County is the Business located physically in?

Does the business employ 50 or fewer employees? Does the business employ 50 or fewer employees? Yes No

Does the business have an active business license in South Carolina? Does the business have an active business license in South Carolina? Yes No

Does the applicant identify as Farm, HBCU student, Women owned business, Small Business, or Public Service agent? Does the applicant identify as Farm, HBCU student, Women owned business, Small Business, or Public Service agent? Yes No

Is your business currently open and operating? Is your business currently open and operating? Yes No

Doing Business As ( DBA)

Business Physical Location Address

Business Mailing Address

Business Phone Number:

Business Email:

Owner First Name:

Owner Last Name:

Owner's Home Address:

New Field

Mailing Address ( if different)

Phone Number:

Owner's Email

Business Owners Date of Birth:

Education Level :

Ethnicity: Ethnicity: Non-hispanic Hispanic

Gender:

Race:

(* If different from business owner)

Participant Last Name:

Participant Home Address:

Mailing Address ( if different)

Participant Phone Number:

New Field

Participants Email:

How long have you been in business? Date of incorporation *

Current Number of Employees:

Business Type: ( sole proprietor, LLC, S-Corp, C-corp, Non Profit, Student

Average Annual Business Revenue

Business NACIS Code(s):

Business Description

Summary of Owner's Experience in industry: *

Summary of how integrating the FAA 107 A Certification credentials will impact your business. *