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

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

Date Business Established: *

Are you registered with the System Award Management (SAM)? *YesNo

Dun and Bradstreet or UEI Number: *

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 *