Black Business Directory Application

Business Name*

Business Category*

Business Address*

Street Address Address Line 2 City State ZIP Code

What are your hours of operation?

Business Owner Name*

First Last

Business Owner Name (Co-owner/ secondary owner)

First Last

Phone (Main)*

Phone (Mobile)

Business/ Owner Email*

Does your business have a website?

Yes
No

Website

Does your business have any social media accounts?

Yes
No

Facebook

Example: https://www.facebook.com/OmegaPsiPhiGA/

Twitter

Example: https://www.twitter.com/OmegaPsiPhiGA/

Instagram

Example: https://www.instagram.com/OmegaPsiPhiGA/

YouTube

Example: https://www.youtube.com/OmegaPsiPhiGA/

Business Product/Service Description*

Please give a brief description of your business and the products/services you provide

What area do you mainly service?

City State

Area of Coverage

Local
National
Global

Are any of the owners members of the "Divine 9"?

Omega Psi Phi
Alpha Phi Alpha
Alpha Kappa Alpha
Kappa Alpha Psi
Delta Sigma Theta
Phi Beta Sigma
Zeta Phi Beta
Sigma Gamma Rho
Iota Phi Theta

Consent*

By submitting the above data, you hereby give the 7th District/Georgia State Organization of the Omega Psi Phi Fraternity, Inc. authorization to post, advertise and promote your business entity. Your submission affirms that all the data entered hereto is accurate and that you are the person authorized to make business decisions for your business entity. Your submission indemnifies the 7th District/Georgia State Organization of the Omega Psi Phi Fraternity, Inc. against any liability related to the release of this information for consumer’s review, consideration of services and subsequent use.

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