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Kansas Minority Enterprise Development
(MED) Week 2021

Minority- and Woman-Owned Business of the Year Nominee Form

BUSINESS INFORMATION
Name of Owner
First Last
Name of Business
Date Established
Primary Business Activity
Address
Street Address Address Line 2 City State ZIP Code
Phone
Email
Which category do you wish to be considered?*
What is the business' industry?
A) Provide background information about the business and owner(s). (45 points maximum)
Owner Details
Owner's Name Title Percentage Owned Ethnicity Gender
Describe how the owner started the business. What inspired the owner to open the business and what steps were taken to establish the business, i.e. classes, research, experience? Were there any obstacles that had to be overcome?
Describe the owner's initial investment to acquire the business.
What is the impact your business has had on your community? Are there any other businesses in the area that offer this service of product?
B) Describe the current financial condition of the business by providing the following information. (35 points maximum)
What is the average gross receipts for the company over the last three years? (information used for rating purposes only and will not be shared with the public.)
Please select the amount that closely reflects the total average gross receipts.
What was your yearly percentage of profit to revenues?
For Fiscal Year 2021
What was your yearly percentage of profit to revenues?
For Fiscal Year 2020
What was your yearly percentage of profit to revenues?
For Fiscal Year 2019
Provide employment (job creation) history of the business for the past three years. For example, how many employees were needed to open the business? How many are currently employed by the business? Full-time, part-time?
Describe the impact of the business' job creation on the community.
What future goals does the owner have for the business?
C) List trade organizations and community involvement of the business and its owner(s). (10 points maximum)
D) List relevant awards received by the business and/or business owner(s). (5 points maximum)
E) Attach any additional information that you believe to be pertinent to the selection process (i.e. written articles, awards received.) (5 points maximum)
Attach Logo (Jpeg, png, pdf)
Drop files here or

Max. file size: 512 MB.
Attach Photos of Owner, Business, or Products
Drop files here or

Max. file size: 512 MB.
Request your State of Kansas Tax Clearance Form
Click here to visit the Department of Revenue Tax Clearance Site
Attach your completed proof of Kansas tax clearance (PDF)
If your tax clearance form is unavailable at the time of submission, please email the completed form to Office of Minority and Women Business Development: kdc_mwbd@ks.gov
Max. file size: 512 MB.

Owner's Name	Title	Percentage Owned	Ethnicity	Gender

Kansas Minority Enterprise Development(MED) Week 2021

Minority- and Woman-Owned Business of the Year Nominee Form

BUSINESS INFORMATION

A) Provide background information about the business and owner(s). (45 points maximum)

B) Describe the current financial condition of the business by providing the following information. (35 points maximum)

Request your State of Kansas Tax Clearance Form

Kansas Minority Enterprise Development
(MED) Week 2021