Client Intake Form We’re looking forward to working with you! Client Intake Form Who referred you?* Your Company's Legal Name*Please also include a "doing business as" if you wish. Your Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Your Title* Business Address*Please include the U.S. county in which your business is located. Street Address ----What county are you in?--- City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Enter Email Confirm Email Website* Business Structure*- select from belowC CorporationSubchapter S CorpPartnershipSole ProprietorNon-ProfitLLCOtherBusiness Start Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Annual Gross Revenue* HiddenLast Year's Export Sales NAICS Codes* What bank(s) does your company use?* Largest Contract Value* Are You Bonded?* Yes No Who are you bonded with? Bonding: How much? HiddenMax/Current Bonding Level ($) What ethnic group best describes you or your company ownership?*- select from belowAfrican AmericanAlaska NativeAmerican IndiansAsianAsian IndianAsian Pacific AmericanNative Hawaiian or Other Pacific IslandersHasidic JewsHispanic AmericanN/ANumber of full time employeesNumber of part time employeesNumber of contractorsTotal Number of Employees*This includes full time, part time and contractors. Number of Employees who identify as a Minority? Does the company accept Government Credit Cards? Yes No Check All Current Certifications or Statuses That Apply* None 8(a) Disadvantaged Business Enterprise (DBE) Economically Disadvantaged Women-Owned Small Business (EDWOSB) Hub Zone Minority Business Enterprise (MBE) Registered in SAM Service-Disabled Veteran Owned Business (SDVOB) Veteran-Owned Business (VOB) Women Business Enterprise (WBE) Women-Owned Small Business (WOSB) GSA Schedule Yes (please provide schedule number below) No Please provide GSA Schedule Number Do you own or lease your space for your business? Yes, I lease my space Yes, I own my business space No If you lease, when does your lease renew? MM slash DD slash YYYY Are you interested in changing your space (downsizing, increasing space, or altering your space)? Yes No List all national, state, & local licensesThis helps us to match you with opportunities.Company Technical Certifications (i.e., ISO 9001, LEED, IT, etc.):This helps us to match you with opportunities.Business Description*Give us a sentence or two about your business.Key Words*Please give us up to 10 key words to help find opportunities for you. (Examples: Construction or real estate or food or marketing services)Did you attend or graduate from Georgia Tech? Yes No Please share your social media links with us - especially LinkedInHiddenSection BreakHiddenNot Approved No Yes I agree that I am a Client of the MBDA Business Center (MBC) in Georgia and provide this information so that I may receive assistance. The MBC will provide assistance as agreed upon by my company and MBC. This service may be at no cost or at costs that are detailed in service agreements. This form demonstrates my company's commitment to be a Client of the MBC in Georgia. Page 1 of 2 Client Intake Form MBDA BUSINESS CENTER Minority Business Development Agency Program Services MBDA Internal/External Client Engagement Form The U.S. Department of Commerce Minority Business Development Agency’s (MBDA) mission is to foster the growth and global competitiveness of U.S. businesses that are minority-owned. MBDA accomplishes its mission by facilitating transactions through referrals; business consulting; contract bid/proposal preparation; loan packaging; and/or matching to contract opportunities and capital sources (i.e., loans, equity, bonding, etc.). In addition, MBDA helps clients to achieve their growth objectives by connecting them with prospective strategic partners through business-to-business matching, teaming arrangements, joint ventures, or other strategic advisory services. Acknowledgement of Client Relationship("client") has engaged with MBDA for business consulting or other services. The services provided by MBDA and/or MBDA Business Centers to the client are subsidized through Federal appropriations. MBDA agrees to provide one or more of the following services: Business Consulting Business Matchmaking Contract Opportunity Sourcing Capital Sourcing Other Services (describe below) Describe other services MBDA does not guarantee any particular outcome or business result on behalf of the client or associated third parties and is not liable for any outcomes or business decisions made by the client or associated third parties.Acceptance of Client Relationship The client agrees to: (a) acknowledge the relationship with MBDA (as demonstrated in this agreement); (b) provide firm contact and profile information; (c) disclose outcome(s) based on the services provided to the client by MBDA and/or MBDA business centers to MBDA and/or MBDA business centers; and (d) provide documentary verification to MBDA and/or MBDA business centers for transactions resulting from services provided pursuant to this engagement. Certification Under this agreement, the client certifies that it is a minority-owned business enterprise (MBE). An MBE is defined as a business that is owned or controlled (greater than 50 percent) by the following persons or groups of persons that are also U.S. citizens or resident aliens admitted for lawful admission to the United States: African Americans, Hispanics, Asian and Pacific Islander Americans, Native Americans (including Alaska Natives, Alaska Native Corporations and Tribal entities), Asian Indians and Hasidic Jews. See 15 CFR § 1400.1. Privacy Disclosure and Information Use By submitting this form, your company agrees to allow the Minority Business Development Agency (MBDA) in Washington, D.C. to share this document, information contained therein, and any supplementary material provided by your company (collectively “Client Engagement Form”) on an as needed basis, with other United States Government agencies to carry out appropriate due diligence and more effectively advocate for your interests. The Client Engagement Form also may be used by MBDA and MBDA Business Centers for the purposes of conducting research, studies, and analysis consistent with the MBDA mission as stated in Executive Order 11625. The Client Engagement Form is considered business confidential and will not be shared with any other person or organization outside the U.S. Government unless the MBDA Headquarters is given permission to do so by your company. All business confidential information will be protected from disclosure to the extent permitted by law. Name*Authorized Client Representative Digital Signature*Date* MM slash DD slash YYYY OMB Control No. 0640-002 Approved - DOC/OGC: 4/21/2015 Page 2 of 2HiddenFor Internal Use OnlyHiddenMBDA Business Center Location HiddenMBDA Business Center Staff HiddenInterview Date MM slash DD slash YYYY HiddenMBDA Staff Referral Name HiddenReferral Date MM slash DD slash YYYY HiddenCRM Certification Date MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged. Δ
