Client Intake Form

We’re looking forward to working with you!

This intake information helps us to match your business with programs and opportunities.

We generally ask you to complete this form when we start our relationship – and then when our funding cycle renews (every five years).

Client Intake Form (2022)

"*" indicates required fields

Who referred you?*

Your Company's Legal Name*

Please also include a "doing business as" if you wish.

Your Name*

Prefix First Last

Your Title*

Business Address*

Street Address ----What county are you in?--- City State ZIP Code

Phone*

Email*

Enter Email Confirm Email

Website*

Business Structure*

Business Start Date*

Annual Gross Revenue*

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Last Year's Export Sales

NAICS Codes*

What bank(s) does your company use?*

Largest Contract Value*

Are You Bonded?*

Yes

Who are you bonded with?

Bonding: How much?

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Max/Current Bonding Level ($)

What ethnic group best describes you or your company ownership?*

Number of full time employees

Number of part time employees

Number of contractors

Total 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

Check All Current Certifications or Statuses That Apply*

GSA Schedule

Yes (please provide schedule number below)

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

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If you lease, when does your lease renew?

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Are you interested in changing your space (downsizing, increasing space, or altering your space)?

Yes

List all national, state, & local licenses

This 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

Please share your social media links with us - especially LinkedIn

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Not Approved

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*

OMB Control No. 0640-002 Approved - DOC/OGC: 4/21/2015

Page 2 of 2

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For Internal Use Only

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MBDA Business Center Location

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MBDA Business Center Staff

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Interview Date

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MBDA Staff Referral Name

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Referral Date

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CRM Certification Date

This field is for validation purposes and should be left unchanged.

Client Intake Form (2022)

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For Internal Use Only

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