Client Registration Form - Minority/Small Business Technical Assistance

First Name *

Last Name *

Email Address *

Mobile Phone

Business Name *

Your Title *

Business Address *

Address 2

City *

State *

Zip/Postal Code *

Business Phone *

Fax

What services are you interested in? *

Who referred you to our business development programs? *

About Your Business

Business Start Date * +

States of Operation

Business Structure

What Industry is your business or businesses in? (Select up to 5) *

If construction related *

Largest projects/contracts completed during the last five years

1) Project Description

1) Value

1) Year

2) Project Description

2) Value

2) Year

3) Project Description

3) Value

3) Year

4) Project Description

4) Value

4) Year

5) Project Description

5) Value

5) Year

Licenses and other registrations

NAIC code

GSA Schedule No.

NAIC code

Licenses 🛈

NAIC code

Union

Yes

No

NAIC code

Other

NAIC code

Other

Business Certifications

SBA (8a) Expiration Date * +

SBA WOSB Expiration Date * +

SBAHUBZONE Expiration Date * +

CUCP DBE Expiration Date * +

CPUC MBE Expiration Date * +

CPUC MWBE Expiration Date * +

DGS DVBE Expiration Date * +

DGS SB Expiration Date * +

SFHRC LBE Expiration Date * +

NMSDC MBE Expiration Date * +

WBENC WBE Expiration Date * +

Other *

Financial Information

Aggregate surety bond capacity *

Per project surety bond capacity *

Gross Revenue (2020 Forecast) *

Gross Revenue (2019 Actual) *

Gross Revenue (2018 Actual) *

Employees

Total Employees *

Full time *

Part time *

Minority *

Business Description

Business Description *

Preferred way to contact *

Phone

Email

Any

Confidentiality Statement

Client understands that ASIAN, Inc.'s business development programs will hold proprietary information disclosed to its' business centers confidential and will not disclose the same to a third party without the permission of client or a court date. *

Business Center Disclosure

ASIAN, Inc.'s business development programs are funded by the U.S. Department of Commerce Minority Business Development Agency and the State of California Governor's office of Business and Economic Development (GO-Biz). This document is a registration form and does not involve any payment from the undersigned or commitment of service. *

Waiver

Client understands that the services provided by ASIAN, Inc.'s business development programs are recommendations only and are not intended as express or implied warranty or guaranty that such services will result in profit or any other determinate result for the client. Client hereby waives any and all right of action against the consultant/analyst, business center, and/or ASIAN, Inc. regarding results of any services provided to client. In the event that any client, any employee, agent or associate of client, or any third party should bring legal action against the consultant/analyst, business center, and/or ASIAN, Inc., client agrees to indemnify and hold the consultant/analyst, business center and/or ASIAN, Inc. harmless against such action, including the payment of any cost and/or attorney fees which may be incurred therein. *

Acceptance to receive service

The information gathered in this form will be entered in the database and will be used to assist your firm with marketing and procurement opportunity matching services. The purpose for collecting this information is to track the development of the minority business for use in statistical surveys and the other research. 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 authorized to make this information available to the public and agree to all the terms and conditions as specified herein. *

Terms and Conditions (Select only 1) *

I hereby certify that the above information is true and complete to the best of my knowledge. This program 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.

This form contains data provided by the client to his/her assigned Business Development Specialist.

Client Signature *

clear

I hereby affirm that this client's form was signed physically and the data appear on the uploaded signed form. *

clear

Upload Scan of Physical Form *

Save & Return

Save your progress and complete this form later. (optional)

Lamar Heystek	Prasad Kolluru
Tony Tang	David Mendoza
Elizabeth Howe	Steven Joe
Manna Zheng	Daisy Tovar
Paula Tran	Porter Wong
Jun Shao	Raymond Au Yeong
Other (specify person/organization) Other (specify person/organization)

Alabama	Alaska	Arizona	Arkansas	California
Colorado	Connecticut	Delaware	Florida	Georgia
Hawaii	Idaho	Illinois	Indiana	Iowa
Kansas	Kentucky	Louisiana	Maine	Maryland
Massachusetts	Michigan	Minnesota	Mississippi	Missouri
Montana	Nebraska	Nevada	New Hampshire	New Jersey
New Mexico	New York	North Carolina	North Dakota	Ohio
Oklahoma	Oregon	Pennsylvania	Rhode Island	South Carolina
South Dakota	Tennessee	Texas	Utah	Vermont
Virginia	Washington	West Virginia	Wisconsin	Wyoming

Limited liability partnership	Limited liability company	C Corporation
Sub Chapter S Corporation	Partnership	Sole Proprietorship
Other For-Profit	Other Non-Profit

Accommodation/Food Services	Administrative Support	Agriculture
Arts and Entertainment	Construction	Educational
Financing	Health Care	Information
Management	Manufacturing	Mining
Professional	Public Administration	Real Estate
Research and Development	Retail Dealer	Service Establishment
Surplus Dealer	Transportation	Utilities
Waste Management	Wholesale Dealer	Other Other

Design/Build	Institutional	Financial	Interior
Residential	Healthcare	Education	Restoration
Multi Family	Public/Municipal	Highway/Road	Other

SBA (8a)	SBA WOSB	SBAHUBZONE	CUCP DBE
CPUC MBE	CPUC MWBE	DGS DVBE	DGS SB
SFHRC LBE	NMSDC MBE	WBENC WBE	Other