Mentor-Protege Application

Key Contact Information
Identify all owners/officers or managing members of your company below and their percentage of ownership.
First Key Contact Name
First Last
Title
Ownership Percentage
Business Phone
Mobile Phone
Email
Second Key Contact Name
First Last
Title
Ownership Percentage
Business Phone
Mobile Phone
Email
Third Key Contact Name
First Last
Title
Ownership Percentage
Business Phone
Mobile Phone
Email

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Company Financial Information
All information submitted herein is kept confidential.
Balance Sheets and Income Statements
Please upload balance sheets and income statements for the last two years of business.
Drop files here or
Largest Customers
Please identify your three largest customers below.
First Customer
Business Name: Phone: Contact Person: Type of Project: Contract Amount: Year:
Second Customer
Business Name: Phone: Contact Person: Type of Project: Contract Amount: Year:
Third Customer
Business Name: Phone: Contact Person: Type of Project: Contract Amount: Year:

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Acknowledgement and Signature
Name of Authorized Person Submitting Application*
First Last
Title*
Date of Submission*
Date Format: MM slash DD slash YYYY
Acknowledgement*
- By checking this box and submitting this application, I certify that the information supplied in this application and any uploaded documentation is accurate. Furthermore, I understand that all submitted information will remain confidential and will only be used for the purposes of the Indy Chamber Hispanic Business Council.

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Mentor-Protégé Application