Women Minority Business Development Center

Technical Business Support (TBS) & Business Assessment Intake

Date of Enrollment

Part I: Client Request for Professional Technical Business Support (Please Complete entire form)

Client Name (Representative of the business)*
Email*
Are you the Owner or Co-owner?
Date of Start of Business
Street Address/PO Box (give business address if currently in business)*
I am requesting professional technical business support from Delta State University's Women Minority Business Development Center*

Part II: Client Intake Section (Client must complete entirely prior to services)

Race (mark only one)*

Ethnicity*
Gender*
Disability*
Veteran*
Registered with the Secretary of State of Mississippi
Legal entity*

Are you currently in business?*
Type of Business (Choose your industry category)*

MDA Women & Minority Certified*
SBA HubZone Certified*
Registered with Northwest Contract Procurement Center*
Do you use Social Media for your business?*
Do you conduct business online?*
What is the nature of professional technical business support you are seeking? (Choose primary category)*

This field is for validation purposes and should be left unchanged.