0640-002 Business Center Client Engagement Form

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 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 match-making
___ contract opportunity sourcing
___ capital sourcing
___ other services (describe) _________________________________.
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, Hispanic-Americans, Asian and Pacific Islander Americans, Native
Americans (including, Alaska Natives, Alaska Native Corporations, and Tribal entities), Asian Indians, and
Hasidic Jews. See 15 C.F.R. § 1400.1.
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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.

_______________________________________
Signature of Authorized Client Representative

____________________
(Date)

_______________________________________
Print Name of Authorized Client Representative
_______________________________________
Name of Business
_______________________________________
Address
_______________________________________
City, State, Zip
_____________________________
Telephone
_____________________________
E-Mail
___________________________________________
Signature of MBDA Business Center Representative

____________________
(Date)

____________________________________________
Print Name of MBDA Business Center Representative
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For Internal Use Only
Business Center Location:

___________________________________________

MBDA Business Center Staff:
Interview Date:

___________________________________________
____________________

MBDA Staff Referral Name:
Referral Date:

___________________________________________
____________________

CRM Certified Date:

____________________

OMB Control No. 0640-002
Approved – DOC/OGC: 4/21/15

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