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<br />TEXAS APPLICATION FOR PAYEE IDENTIFICATION NUMBER
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<br />~. Shaf:Jedareas forsrafe agency IJse only
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<br />Pag. 2.
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<br />P.~ nurroer {Sa/'TJJ& as 119m2)
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<br />~~. ~ ! /1 i..fl;...' b16,612~"2.:r3 I '3'
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<br />15. BUSINESS INFORMATION FOR STATISTICAL REPORTING-~:Abusiness enterpriscls~~a corporation, pannershlp, sole proprietorship or
<br />~ other lega! eotH)' tormed for the purpose oi making a profr\.Please cr;ec'~ all categories that apply to your business~ ~ Providing rhe
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<br />I~. ~ ;r:::;~eu:::~::::'::~;::o; :Sn :;~:r:r:'e which IS mdepender,tlyowneo and operated a nd has fewer than 1 O~ empioyees orhas
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<br />r ~ ~,~~lesslhan$l;OOO;OOOjn annual gross receipts ~ ~ ~~ ~~~:::~:~~:~~~~'. ~ ~ ~~~,~ ~~ ~~ ~~
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<br />~l~~~ ~~~~ ~..~.::=lDjsadVarllaged Business Enterprise ~. an~~terpriseatleast 51%01 which is owned or controlled oy one or more~scic:iaIIY
<br />~. :1.::' ~ ~~~~ :~~ ~ ~ ~ disadvantagedpers()n~? ~Jease check the category which best descfibes your.bu~iness ownership, ~~ ~. ~ ~ ~
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<br />~....Jj < ~DD Black ,.~ 0 HESiSkPI~ma,noiC ~ o American Indian
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<br />~.~116, : BUSH-lESS DESCRIPTioN CODES !ForSl~teAPency~seonIY)>~~~~~
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<br />'~.. Hi20.AGENCY1DENTIFICA TION
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<br />:::::JWom8nc;"nedB~sinessEnterprise ~n enterprise at least51% ofwhic~iso""nedClrcontrolled bYlVo~en, . ~
<br />Doyou have:edissdvsntegecibuslness enlerprlsecer11flcBleon fiJewirhtheTeX8S Depsrtmenlof Commerce?
<br />~ --,Other. business enterprise ~~~nenterprisenol oescribedin one of.thecategoriesshown above:
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<br />8usi.nessDescriPtiori~C~cle lor thlsousmess..1f not certifje~ withTDOC.acld1 OOtDl'1eap;:>ropnatecode: .~~
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<br />Ol::~~Small:':'~~ ~~~ ~ ~ ~ 18 :..:.DisaavantagedEskimc)
<br />~ ~~. ~ ~:~ 1.9~:Small.Disadvantaged~~Eskimo~.:
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<br />~Womano.vned~Dlsadvantaged8Iack~ ~
<br />,:Sman Woman Owned Disaavantaged BlacK,:~:.:~.
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<br />06 'Disadvantagea HispanIC ~~ ~
<br />07~. Small Disadvantagec Hispanic<~~ . ~
<br />~OSW Or:1an Ow ned.oi sadvantag ecHispariic'
<br />~ 09: Sma 1\ W omar, Owned Disadvan tagedH is panic~/~
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<br />~ 27::$maWDisadvantaged.:Other ~
<br />~ 28~:W~omanOwnedDisacivamaged::Other ~ :~~. ~~~. ..~~ ~~~, ~~~~~ ~
<br />29:.:Small Woman (N.<ned Disadvantaged :~:01her .
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<br />io~: Disadvantaged America.nlndiari ~. . ~ ~ ~
<br />~.~., 1 :Small:.DisadvimtagedAmencan:Jndian<>:> ~.~~~~ ~~
<br />~~~'12WomanOwned~DisadvantagedAmer\Cari.Jndiaiij~... .~~~:
<br />., 3 ~ . :Sman WomanOVVriedDisadvantagedAmehcanlndiani
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<br />Small :Dj sadvantagedAsia n:A merical)<.... ~ . ,:' ~.' ~ ~ ~:
<br />.Vycma.nOwned Disadvantaged Asian ~American
<br />: Sma Ii ~Woman Owned DisadvamagedAslan ~Am8ncan:.~'~
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<br />>jJ7. D:PAY M EN TiASl:i IGNM ENT lNFORMA TION ..:NcriE:~:c;P)'r:;ltheEssIQi}!7J~Qtf?g~eerrrenr~between'Pay~e$rrrZSrbeatlaC~ed....~~~ .~~ ~
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