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TERO Contractor Application

Important Note: As a part of determining whether to approve a Company as a TERO Certified Company, the TERO Office may conduct background and credit checks on the Company and its owners and employees and may decline to certify a Company based on the results of those checks.

Company Information

Name of Company

Website

http://

Address of Business

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Business Phone

(###)

###

####

Number of Tribal Members Employed

Number of other Native Americans Employed

Total Number of Employees

Type of Business

Please provide a list of business areas and types of work

Federal ID (TIN)

Date Business was Formed

YYYY

Type of Business

Single Business

Joint Venture

Contact Information

Contact Name

First Name

Last Name

Contact Phone

(###)

###

####

Ownership

Type of Ownership

Sole Proprietor

Partnership

Corporation

Limited Liability Company

Percent of Company Owned by a Tribal Member

Percent of Company Owned Other Native American

Owner Name

First Name

Last Name

Owner Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Tribal Affiliation

Enrollment ID Number

Percentage Owned

Position/Title

LIST ANY MANAGEMENT FEE, EQUIPMENT RENTAL, BONUSES OR OTHER ARRANGEMENTS THAT WILL PROVIDE PAYMENT TO NON-INDIAN OWNERS BEYOND THEIR SHARE OF PROFITS AND SALARIES, AS INDICATED ABOVE.

DESCRIBE OR ATTACH ANY STOCK OPTIONS OR OTHER OWNERSHIP OPTIONS THAT ARE OUTSTANDING AND ANY AGREEMENTS BETWEEN OWNERS OR BETWEEN OWNERS AND THIRD PARTIES WHICH RESTRICT OWNERSHIP OR CONTROL OF INDIAN OWNERS.

IDENTIFY ANY OWNER OR MANAGEMENT OFFICIAL OF THE NAMED COMPANY WHO IS OR HAS BEEN AN EMPLOYEE OF ANOTHER COMPANY THAT HAS AN OWNERSHIP INTEREST IN OR A PRESENT BUSINESS RELATIONSHIP WITH THE NAMED COMPANY; PRESENT BUSINESS RELATIONSHIPS INCLUDE SHARED SPACE, EQUIPMENT, FINANCING, OR EMPLOYEES AS WELL AS BOTH COMPANIES HAVING SOME OF THE SAME OWNERS.

INDICATE IF THIS COMPANY OR OTHER COMPANIES WITH ANY OF THE SAME OFFICERS HAVE PREVIOUSLY RECEIVED OR BEEN DENIED CERTIFICATION OR PARTICIPATION AS AN INDIAN PREFERENCE FIRM AND DESCRIBE THE CIRCUMSTANCES. INDICATE THE NAME OF THE CERTIFYING AUTHORITY AND THE DATE OF SUCH CERTIFICATION OR DENIAL.

Certification

I HEREBY CERTIFY THAT THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. I FURTHER CERTIFY THAT I HAVE READ THE APPLICABLE ORDINANCES, REGULATIONS, CRITERIA AND PROCEDURES OF THE MASHPEE WAMPANOAG TRIBE AND DO HEREBY SUBMIT TO THE JURISDICTION PROVIDED THEREIN.

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TERO Contractor Application