Make Mine Mississippi Online - Registration Required items are noted with (*) please fill out the entire form.
Company Name*:
Contact Person:	First Name * Initial Last Name * Title Dr. Hon. Mr. Mr. & Mrs. Mrs. Ms. Rev.
Address*:
City*:		State*: Zip*:  County* Select County Adams Alcorn Amite Attala Benton Bolivar Calhoun Carroll Chickasaw Choctaw Claiborne Clarke Clay Coahoma Copiah Covington DeSoto Forrest Franklin George Greene Grenada Hancock Harrison Hinds Holmes Humphreys Issaquena Itawamba Jackson Jasper Jefferson Jefferson Davis Jones Kemper Lafayette Lamar Lauderdale Lawrence Leake Lee Leflore Lincoln Lowndes Madison Marion Marshall Monroe Montgomery Neshoba Newton Noxubee Oktibbeha Panola Pearl River Perry Pike Pontotoc Prentiss Quitman Rankin Scott Sharkey Simpson Smith Stone Sunflower Tallahatchie Tate Tippah Tishomingo Tunica Union Walthall Warren Washington Wayne Webster Wilkinson Winston Yalobusha Yazoo Out of State
Telephone Number*:		Fax*:
Email:
Web Site:	(Example: www.makeminemississippi.com do not put the "http://" in front)
Type of Business (check all that apply)*
Distributor	Processor Producer Retailer
Wholesaler	Association Manufacturer
Category*:	Select A Category Apparel/Textile Products Aquaculture/Seafood Arts, Crafts, & Entertainment Association Baked Goods Beverages Chemicals Containers Cosmetic/Health Care Dairy Electronics Emu/Ostrich Feed & Seed Fruits, Vegetables, Nuts Furniture Government Honey Horticulture Ice Livestock & Supplies Manufactured Products Milled Products Office Products Outdoor Goods Processed Meat/Poultry Publication Restaurant Retailer Specialty Foods Wood Products
Product*:
Brand Name(s):
Will you utilize the Make Mine Mississippi logo for your products?*   Yes No
Location of processing facility:  Location of packing facility:
Where is the bulk of your business?* Local     In-State Regional  National  International
Number of Employees*:	1-10 11-50 51-100 More than 100
Is your product(s) at least 51% produced, processed, or manufactured in Mississippi?* Yes No