NDAREC Rural Development Request for Services

Name

Date

Business/Organization name

Address (city/state/zip)

Email address

Phone number

Reason for inquiry

Type of assistance requested

How did you hear about us?

Demographic information

The following information is requested because some of our programs are supported in part by federal grants. Demographic information is voluntary and at the discretion of the person completing the form. Demographic information is used by the Federal Government for statistical data only and will not be used to determine a client's eligibility for programs or services for which they apply.

Race/Ethnicity (Note: Select all that apply)

American Indian or Alaskan Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

Sex

Male

Female