DCMBEC CLIENT FORM

CLIENT FORM

PRIMARY CONTACT INFORMATION

Name		Date
Email		Phone

COMPANY INFORMATION

Company Name			Phone
Address			Website
Address cont'd			Ethnicity of Principal Owner
City, State, and Zip

BUSINESS INFORMATION

Business Type and Description

Number of
Employees:

Full Time:

Part Time:

Minority:

Business Start Date:

Business Structure (Please choose one)

Corporation	Sole Proprietorship
Partnership	LLC

Annual Sales:

DCMBEC Information Disclosure/ Minority Status

The purpose for collecting information is to track the development of the minority business for use in statistical surveys and other research. In that regard, the information entered into the form will be available to the general public.

In addition, information collected on this form will be made available to federal, state and local agencies for use in statistical surveys and other research to track the development of minority businesses. By entering data in this form you certify that you are authorized to make this information available to the public and agree to all the terms and conditions as specified herein.

E-Signature Date

"I certify that I represent a Minority Business Enterprise. DCMBEC defines a Minority Business Enterprise as a business which is owned or controlled by socially or economically disadvantaged persons who are members of one of the following eligible groups: African Americans, Aleuts, Asian Indians, Asian Pacific Americans, Eskimos, Hasidic Jews, Native Americans, Puerto Ricans, and other Spanish-Speaking Americans. I understand that false certification may result in a fine or imprisonment under applicable Federal law.”

E-Signature Date

Ø Info@dcmbec.org

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