MINORITY AND/OR WOMAN OWNED BUSINESS FOUNDATION IMPACT AWARD FORM Minority-Owned or Woman-Owned Business Foundation Impact Award Form Name First Last Business * Minority and/or Woman Owned Business We are a minimum 51% Minority-Owned Business. We are a minimum 51% Woman-Owned Business. Note, if you are both, please check both boxes. Purpose of Business Business Website Email Stable or Growth in Employees over the last calendar year - Jan 1, 2023 to Dec 31, 2023 In a few words, tell us how many employees you have and if you have been able to maintain or grow that number over the last three years. ECONOMIC FOOTPRINT: If you use Douglas County businesses for services or business needs, that is part of your economic footprint impact. We have listed several services below, check them if you use a Douglas County business to fullfill those needs, and then list as many of them as you can in the following text box. Economic Footprint - Local Businesses/Services we use. Accounting Advertising Attorney/Legal Services Bank(s)/Financial Services Charitable Organizations Cleaning Company Car Purchase/Lease Computer/Electronic Maintenance or Purchase Florists Gifts Grocers Insurance Internet Services Landscaping / Lawn Services / Snow Removal Laundry/Dry Cleaning Office Supplies Painting Pest Control Phone Plumbing Services Printing - stationery, posters, flyers etc Promotional Items Remodeling/ Construction Roofing Security Other, please include in box below. List as many of the businesses in the above Economic Footprint checked above as you can. PHILANTHROPIC FOOTPRINT: Please answer the questions below and give details/explanation as appropriate. Do you donate time locally? Do you allow your employees to donate time locally on the job? Do you belong to any Douglas County not-for-profit organizations? And do you serve as an officer or on the board for any Douglas County not-for-profit organizations? Do you donate money or in-kind donations to any Douglas County not-for-profit organizations? If so, please list organization name(s), (not a dollar amount). BUSINESS COLLABORATION FOOTPRINT: Do you collaborate with other businesses to achieve business goals? (i.e. Do you work with local businesses, buy from local businesses, and use services from local businesses rather than resourcing from a non-local business whenever possible?) If so, please explain below. Do you or your business have any policies or mission to work locally? If so what are they and why? Please list anything else you’d like to tell us about your company and your economic footprint?
