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 assists 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 name) 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 match-making; ☐ contract opportunity sourcing; ☐
capital sourcing; ☐ and/or other services
.
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 outcomes(s) based on the services provided to the client by MBDA and/or
MBDA Business Centers, (d) provide documentary verification to MBDA and/or MBDA Business Centers for transactions
resulting from services provided pursuant to this engagement.
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. Information provided by the client to MBDA and MBDA Business Centers will
remain confidential. MBDA and MBDA Business Centers will take reasonable action to restrict access to such information by
non-government entities. All information will remain confidential to the fullest extent of the law. In providing services to
clients, MBDA does not guarantee any particular outcome or business decision on behalf of third parties and is not liable for
any outcomes or business decisions made by third parties.
Print Name:
Authorized Client Representative
Signature:
__________________________________________________
Date
Print Name:
MBDA and/or MBDA Business Center Representative
Date
Signature: __________________________________________________
Page 1 of 6
COMPANY CONTACT INFORMATION:
Company
Contact, Title
Address
City, State, Zip
Telephone
Email
FOR INTERNAL USE ONLY:
Processing MBDA Business Center Location: ____Arizona_________________________________________________
MBDA and/or MBDA Business Center Staff Member: _____________________________________________________
Print Name: ______________________________________________________________________________________
Signature: _______________________________________________________________________________________
Date: ___________________________________
Approved by OGC: 04/08/2011
Page 2 of 6
Phoenix MBDA Business Center
CLIENT SERVICE APPLICATION
PRIMARY CONTACT
Name:
Phone:
Email:
COMPANY INFORMATION
Company Name:
Address:
City, State, ZIP:
Country:
Web Site:
Ethnicity: U.S. Citizen: ☐ Yes ☐ No If no, alien registration number
 Hispanic  African American  Asian/Pacific Islander  Puerto-Rican
 Native American
 Eskimo/Aleut  Other
Service Disabled Veteran: ☐ No ☐ Yes
BUSINESS INFORMATION
Business Start Date:
Business Type: ☐ Sole Proprietor ☐ Corporation ☐ Partnership ☐ Limited Liability Co.
State of Incorporation:
Business Description:
Keywords:
Number of Employees Full time:
Part time:
Minority:
Annual Sales:
Annual Export Sales: $
Export Request: ☐ No ☐ Yes
Would you like more information on ☐ No ☐ Yes
export opportunities?
Special Initiative Programs:
☐ American Recovery and Reinvestment Act
Are you interested in Special ☐ Gulf Coast Recovery Program
Initiative Programs?
Accounting Period Closes:
Facilities Security Level:
Page 3 of 6
Max Bonding Level ($): $
Current Bonding Level $
Is this company registered with ☐ No ☐ Yes
CCR?
DUNS Number:
I'm interested in micro purchases ☐ No ☐ Yes
($3000.00 or less) paid by
Government purchase cards:
Accept Government Credit Card: ☐ No ☐ Yes
Largest Contract Value: $
Value Added Network Number:
CAGE Code:
Minority-Owned Certification: ☐ MBE ☐ SBE
☐ DBE
☐ 8(a) ☐ SDB
☐ GCMSDC
☐ Other
CERTIFICATION STATUS
(1) Agency Name:
Number:
Date:
(2) Agency Name:
Number:
Date:
(3) Agency Name:
Number:
Date:
INDUSTRY CODES
NAICS:
Operating Locations ☐ USA (All) ☐ Arizona
☐ Other States
How did you hear about the
MBDA Business Center?
Page 4 of 6
“Phoenix”
Online Opportunity Database
“Phoenix” Online Opportunity Database
“Phoenix”
Online
Opportunity Database
Terms
of Use
Terms
of Use
Terms of Use
Please indicate
your acceptance to receive service.
Please indicate your acceptance to receive service.
indicate
your
acceptance
to receive
service.
Your dataYour
willPlease
not
be
accepted
if this
step
is not
completed.
data will
not be accepted
if this
step
is not completed.
Your data will not be accepted if this step is not completed.
"I certify that
I represent
Minority aBusiness
Enterprise.
MBDA defines adefines
Minority Business
Enterprise
as
"I certify
that II a
represent
Business
Enterprise.
Business
Enterprise
certify
represent
a Minority
Minority
Business
Enterprise. MBDA
MBDA
defines a
a Minority
Minority
Enterprise as
as
a business "I
which
is that
owned
or
controlled
by socially
orsocially
economically
disadvantaged
persons Business
who
are who
a
business
which
is
owned
or
controlled
by
or
economically
disadvantaged
persons
a business which is owned or controlled by socially or economically disadvantaged persons who are
are
members of
one of theone
following
eligible groups:
African Americans,
Aleuts, Asian Indians,
Asian Pacific Pacific
members
members of
of one of
of the
the following
following eligible
eligible groups:
groups: African
African Americans,
Americans, Aleuts,
Aleuts, Asian
Asian Indians,
Indians, Asian
Asian Pacific
Americans,Americans,
Eskimos,
Hasidic
Jews,
Native
Americans,
Puerto
Ricans,
and
other
Spanish-Speaking
Eskimos,
Hasidic
Jews,
Native
Americans,
Puerto
Ricans,
and
other
Spanish-Speaking
Americans, Eskimos, Hasidic Jews, Native Americans, Puerto Ricans, and other Spanish-Speaking
Americans.Americans.
I understand
that false that
certification
may resultmay
in aresult
fine or
under applicable
II understand
false
in
a
under
Americans.
understand
that
false certification
certification
may
result
in imprisonment
a fine
fine or
or imprisonment
imprisonment
under applicable
applicable
Federal law."
law."
Federal law."
Federal
Signature:
___________________________________
Date: _____________
►______________________________________
_______________
Signature:
___________________________________
Date: _____________
Signature
Date:
PRIVACY NOTICE:
PRIVACY NOTICE:
The information entered in the Phoenix database will be used to assist your firm with marketing and
The information
enteredopportunity
in the Phoenix
database
will be used to assist your firm with marketing and
procurement
matching
services.
procurement opportunity matching services.
The
The purpose
purpose for
for collecting
collecting this
this information
information is
is to
to track
track the
the development
development of
of the
the minority
minority business
business for
for use
use in
in
The purpose
for collecting
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for use
statistical
surveys
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other
In
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In that regard, the information entered into the form will be
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available to the general public.
In
In addition,
addition, information
information collected
collected on
on this
this form
form will
will be
be made
made available
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to federal,
federal, state
state and
and local
local agencies
agencies
for
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research
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federal, state
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use in statistical
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track the to
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By
entering data in this form you certify that you are authorized to make this information available to the
for use in statistical
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other
to track
the authorized
development
of minority
businesses.
By
entering data
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form
youresearch
certify that
you are
to make
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to the
public and agree to all the terms and conditions as specified herein.
public
and form
agreeyou
to all
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andare
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as specified
entering data
in this
certify
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authorized
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this information available to the
public and agree to all the terms and conditions as specified herein.
Signature: ___________________________________ Date: _____________
►______________________________________
_______________
Signature: ___________________________________ Date: _____________
Signature: ___________________________________
Date: _____________
Signature
Date:
Notice
Notice
Consent to Information Collection / Sharing: Generally, Minority Business Development Agency
Notice
Consent
to Information
Collection
Sharing: Generally,
Minority
Business
Developmentagency,
Agency
will
not share
any personally
identifiable/ information
you give us
with any
other government
will not organization,
share any personally
identifiable
you giveorusaswith
any other
government
agency,
private
or the public,
exceptinformation
with your consent
required
by law.
By pressing
the
Consent to
Information
Collection
/ Sharing:
Minorityor
Business
Development
Agency
private
organization,
or the
public,
except Generally,
with
your consent
as required
by law.
pressingstated
the
'Submit'
button, each
client
constitutes
consent
to use the
information
forBy
purposes
will not share
any policy.
personally
identifiable
you
give usto
with
any
other
government
'Submit'
button, each
clientinformation
constitutes
consent
use
the
information
for agency,
purposes stated
in
this
private organization,
or the public, except with your consent or as required by law. By pressing the
in this policy.
'Submit' button,
each Protection:
client constitutes
consent
to use
the information
purposes
stated
Information
The Minority
Business
Development
Agency for
will protect
all information
in this policy.
consistent
withProtection:
applicable law
including,
not limited
to, the Privacy
1974 and
the Freedom of
Information
The
Minority but
Business
Development
AgencyAct
willofprotect
all information
Information
Act.applicable law including, but not limited to, the Privacy Act of 1974 and the Freedom of
consistent with
Information
Protection:
Information
Act. The Minority Business Development Agency will protect all information
Rights under
the Privacy
Information
the
Act the
canFreedom
be foundof
on the
consistent Your
with applicable
law including,
but Act:
not limited
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Privacy Act
ofPrivacy
1974 and
following
Webunder
site: http://www.cftc.gov/foia/foiprivacyact.htm
Your
the Privacy Act: Information concerning the Privacy Act can be found on the
Information
Act. Rights
following Web site: http://www.cftc.gov/foia/foiprivacyact.htm
►
Your
Rights
the (Billable
Privacy Act:
Information
Annual
fee:under
$100.00
each
year) concerning the Privacy Act can be found on the
following Web site: http://www.cftc.gov/foia/foiprivacyact.htm
Check all that apply and sign to the right to
accept our basic services that include bid
opportunities, referrals, visibility, access to
financing and lots more all year.
☐ April 01, 2012 to March 31, 2013 (1 year)
OWNER/REPRESENTATIVE: (PLEASE PRINT)
►
Signature
Date
☐ April 01, 2013 to March 31, 2014 (1 year)
►
☐ April 01, 2014 to March 31, 2015 (1 year)
MBDA Center Representative: Signature/Date
☐ April 01, 2015 to March 31, 2016 (1 year)
Page 5 of 6
Plan of Action
Center Responsibilities
Actions
Person(s)/
(what will be done)
responsible
Date to be
completed
Resources required
(cost)
1.
2.
3.
4.
5.
6.
Notes:
Page 6 of 6