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).

"*" 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 for Previous Calendar Year*

Please enter a number greater than or equal to 1.

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Annual Gross Revenue*

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Last Year's Export Sales

NAICS Codes*

Your six digit NAICs code

What bank(s) does your company use?*

Largest Contract Value*

Please enter a number greater than or equal to 1.

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Largest Contract Value*

Are You Bonded?*

Yes

Who are you bonded with?*

Bonding: How Much?*

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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 Minority?

Minority, in this context, refers to a member of an ethnic minority group.

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Number of Employees who identify as a Minority?

Minority, in this context, refers to a member of an ethnic minority group.

Does the company accept Government Credit Cards?

Yes

Business Designation(s)*

Woman-owned

Minority-owned

Veteran-owned

Check All Certifications That You Currently Hold*

GSA Schedule

Yes

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*

Please provide a brief description of your business (2-3 sentences).

Key Words*

Please provide up to 10 key words to help us find opportunities for you. Key words should be typed out and separated by commas (ex: dry wall, painting, masonry, construction)

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Key Words*

Please provide up to 10 key words to help us find opportunities for you. Key words should be typed out and separated by commas (ex: dry wall, painting, masonry, construction)

Did you attend or graduate from Georgia Tech?

Yes

Please share your social media links with us - especially LinkedIn

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Section Break

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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 minority business enterprises (MBEs). MBDA accomplishes its mission by funding and working cooperatively with Business Centers that assist clients with facilitating transactions through referrals, business consulting, contract bid/proposal preparation, loan packaging, and/or matching contract opportunities and capital sources (i.e., loans, equity, bonding, etc.). In addition, Business Centers help 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

TThe client agrees to: (a) acknowledge the relationship with Business Center (as demonstrated in this agreement); (b) provide firm contact and profile information; (c) disclose to MBDA and/or Business Center outcome(s) based on the services provided to the client by Business Center to MBDA; and (d) provide documentary verification to MBDA and/or Business Center for transactions resulting from services provided pursuant to this engagement.

Certification

Under this agreement, the client certifies under penalty of perjury that it is a minority business enterprise (MBE), as defined by the MBDA Act. 15 U.S.C. §§ 9501(9), (15). A minority business enterprise (MBE) under the MBDA Act is a business enterprise owned and controlled by at least one socially or economically disadvantaged individual. 15 U.S.C. § 9501(9). A socially disadvantaged individual is an individual who has been subjected to racial or ethnic prejudice or cultural bias because of the identity of the individual as a member of a group, without regard to any individual quality of the OMB Control No. 0640-0002 Expiration Date: 01/31/2026 2 individual that is unrelated to that identity. 15 U.S.C. § 9501(15). An economically disadvantaged individual is an individual whose ability to compete in the free enterprise system been impaired due to diminished capital and credit opportunities, as compared to others in the same line of business and competitive market areas, because of the identity of the individual as a member of a group, without regard to any individual quality of the individual that is unrelated to that identity. 15 U.S.C. § 9501(15). An individual that identifies as a member of one or more of the following groups is presumed to be socially or economically disadvantaged: Black or African American; Hispanic or Latino; American Indian or Alaska Native; Asian (including South Asian); Native Hawaiian or other Pacific Islander; and Hasidic Jews. 15 U.S.C. § 9501(15). An individual does not need to identify as a member of one of these groups to be a socially or economically disadvantaged individual eligible to receive Business Center services under the MBDA Act.

Privacy Disclosure and Information Use

By submitting this form, your company agrees to allow the Business Center and/or MBDA 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 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 Business Centers for the purposes of conducting research, studies, and analysis consistent with the MBDA mission as stated in the MBDA Act. 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 MBDA 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

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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

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Number

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Number

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Number

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Post Custom Field

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Number

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Number

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

Client Intake Form