Miller-Valentine Group – Building Solutions

General Company Information
*Required Fields

*Firm Name:	*Business Phone:

*Street Address:	Business Phone #2:

*City:	*Business Fax:

*State:	Other Fax:

*Zip:	Website:

*Annual sales volume:	*Scopes of Work Performed:

List all C.S.I. divisions that apply to your business:

Are you a Small Business Enterprise?

Yes

In which of these markets does your company work? (check all that apply)

	Dayton
	Cincinnati
	Ft. Wayne, IN
	N. Kentucky

	Columbia, SC
	Columbus
	Other:

Remittance/Payment address (if different from above):

City:

State:

Zip:

Incorporated:

Yes

Federal Tax ID #:

Individuals with your firm who would do business with Miller-Valentine:
(Include Sales Contacts, Project Managers, CAD Operators, Accounts Payable, Shipping Manager, etc.)

Contact name:	Business Fax:

Contact title:	Other Fax:

Business phone:	Mobile phone:

Business phone #2:	Pager:

E-mail:

Contact name:	Business Fax:

Contact title:	Other Fax:

Business phone:	Mobile phone:

Business phone #2:	Pager:

E-mail:

Contact name:	Business Fax:

Contact title:	Other Fax:

Business phone:	Mobile phone:

Business phone #2:	Pager:

E-mail:

Contact name:	Business Fax:

Contact title:	Other Fax:

Business phone:	Mobile phone:

Business phone #2:	Pager:

E-mail:

Prior to sending your information, we recommend double-checking
to make sure you have filled in the necessary fields.