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Indiana Procurement Assistance & Certification Training (INPACT) Initiative Client Registration Form

By completing the below form, you (“client”) acknowledge engagement with the Indiana MBDA Business Center (INPACT Initiative) for business consulting or other services. The services provided by the Business Center to the client are subsidized through federal appropriations.  The MBDA-funded Business Center agrees to provide one or more of the following services to the client:

  • business consulting
  • business match-making
  • contract opportunity
  • sourcing capital sourcing
  • other services
Is your business address a commercial address or residential address? Addresses of residence-based businesses will be kept confidential and can only be accessed by approved INPACT staff.*
Please select how your business identifies as SEDI according to the definitions below.*
(1) Self-certified the business is owned and controlled by individuals who have had their access to credit on reasonable terms diminished as compared to others in comparable economic circumstances, due to their:

     a. membership of a group that has been subjected to racial or ethnic prejudice or cultural bias within American society

     b. gender

     c. veteran status

     d. limited English proficiency

     e. disability

     f. long-term residence in an environment isolated from the mainstream of American society

     g. membership of a Federally or state-recognized Indian Tribe -long-term residence in a rural community

     h. residence in a U.S. territory -residence in a community undergoing economic transitions (including communities impacted by the shift towards a netzero economy or deindustrialization)

     i. membership of an “underserved community” as defined in Executive Order 13985

          i. individuals who belong to communities of color, such as Black and African American, Hispanic and Latino, Native American, Alaska Native and Indigenous, Asian American, Native Hawaiian and Pacific Islander, Middle Eastern, and North African persons

          ii. individuals who belong to communities that face discrimination based on sex, sexual orientation, and gender identity (including lesbian, gay, bisexual, transgender, queer, gender non-conforming, and non-binary (LGBTQ+) persons)

          iii. persons who face discrimination based on pregnancy or pregnancy-related conditions

          iv. Parents

          v. Caregivers

          vi. individuals who belong to communities that face discrimination based on their religion or disability

          vii. first-generation professionals or first-generation college students

          viii. individuals with limited English proficiency

          ix. Immigrants

          x. individuals who belong to communities that may face employment barriers based on older age or former incarceration

          xi. individuals who belong to communities that may face employment barriers based on older age or former incarceration

          xii. persons who live in rural areas

          xiii. veterans and military spouses

          xiv. persons otherwise adversely affected by persistent poverty, discrimination, or inequality.

(2) Self-certified the business is owned and controlled by individuals whose residences are in CDFI Investment Areas, as defined in 12 C.F.R. § 1805.201(b)(3)(ii). Visit https://www.cdfifund.gov/cims to quickly determine if your residence is in a CDFI Investment Area.

(3) Self-certified the business will build, open, or operate a location in a CDFI Investment Area, as defined in 12 C.F.R. § 1805.201(b)(3)(ii)

(4) Self-certified the business is located in a CDFI Investment Area, as defined in 12 C.F.R. § 1805.201(b)(3)(ii)

Acknowledgement of Client Relationship

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 Business Center (as demonstrated in this agreement); (b) provide firm contact and profile information; (c) disclose to MBDA and/or Business Center outcome(s) based on the services provided to the client by Business Center to MBDA; and (d) provide documentary verification to MBDA and/or Business Center for transactions resulting from services provided pursuant to this engagement.

Certification

Under this agreement, the client certifies under penalty of perjury that it is a minority business enterprise (MBE), as defined by the MBDA Act. 15 U.S.C. §§ 9501(9), (15). A minority business enterprise (MBE) under the MBDA Act is a business enterprise owned and controlled by at least one socially or economically disadvantaged individual. 15 U.S.C. § 9501(9). A socially disadvantaged individual is an individual who has been subjected to racial or ethnic prejudice or cultural bias because of the identity of the individual as a member of a group, without regard to any individual quality of the individual that is unrelated to that identity. 15 U.S.C. § 9501(15). An economically disadvantaged individual is an individual whose ability to compete in the free enterprise system been impaired due to diminished capital and credit opportunities, as compared to others in the same line of business and competitive market areas, because of the identity of the individual as a member of a group, without regard to any individual quality of the individual that is unrelated to that identity. 15 U.S.C. § 9501(15). An individual that identifies as a member of one or more of the following groups is presumed to be socially or economically disadvantaged: Black or African American; Hispanic or Latino; American Indian or Alaska Native; Asian (including South Asian); Native Hawaiian or other Pacific Islander; and Hasidic Jews. 15 U.S.C. § 9501(15). An individual does not need to identify as a member of one of these groups to be a socially or economically disadvantaged individual eligible to receive Business Center services under the MBDA Act.

Privacy Disclosure and Information Use

By submitting this form, your company agrees to allow the Business Center and/or MBDA 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 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 Business Centers for the purposes of conducting research, studies, and analysis consistent with the MBDA mission as stated in the MBDA Act. 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 MBDA is given permission to do so by your company. All business confidential information will be protected from disclosure to the extent permitted by law.