Houston MBDA Export Center Client Intake Form Company Name: * Contact Name: * Phone: * Title: * Cell: * Email: * Mailing Address: * Address Line 2: Website: * City / State / ZIP Code: * NAICS Codes: * How did you hear about the Houston MBDA Export Center? *InternetPartner OrganizationEmailClientEventOther Are you a United States Citizen? *YesNo Demographic Information Ethnicity of Majority Business Ownership *African AmericanAlaska NativeAsian AmericanIndian AmericanHasidic Jewish AmericanHispanic AmericanNative AmericanPacific IslanderOther Gender of Majority Business Owner *FemaleMaleMale/Female 50/50 Certifications: *WBE/WOSBMBEHUBZoneVOSB/SDVOSBSDB/8(a)Other Business Information Date Business Established: * Are you registered with the System Award Management (SAM)? *YesNo Dun and Bradstreet or UEI Number: * What is your current business status? *Established - Generated revenue more than 2 yearsStart-Up - Generated revenue 2 years or lessPre-venture CorporationPrivateS CorporationPublicLimited LiabilitySole ProprietorshipPartnership What industry best describes your business? *EnergySupply Chain and LogisticsHealthcareOil and GasInformation TechnologyPetrochemicalImport-ExportProject ManagementManufacturingTechnologyInnovation / PatentConstructionRetailEducation and TrainingWholesale - TradeOther In what state is your company incorporated? *—Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming What is your current annual revenue? * What are your annual export sales? * Signature: * Date * There is NO COST for Export Plan Assistance or Training.