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SBTRC Intake Form

U.S. Department of Transportation
Small Business Transportation Resource Center
Regional Center Intake Form

Public Burden Statement
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2105-0554. Public reporting for this collection of information is estimated to be approximately 5 minutes per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, U.S. Department of Transportation, Room E31-311, 1200 New Jersey Ave, SE, Washington, D.C. 20590.

PART A - CLIENT CONTACT INFORMATION

Full Legal Name of Business *

Full Street Address of Primary Business Location *

Website

Last Name *

First Name *

Title *

Email Address *

Phone

Fax

PART B - BUSINESS INFORMATION

Dun & Bradstreet(DUNS) # *

Registered in Central Contractor Registration (ccr.gov) *

YesNo

Type of Business Formation

Primary Trade or Services Provided

Type of Contractor *

PrimeSubcontractor

Length of Time in Continuous Operation

Number of Employees (Last 3 Years)

Year 1:
Year 2:
Year 3:

Revenue (Last 3 Years)

Year 1:
Year 2:
Year 3:

Certifications

*Check all that apply
DBE States
8(a)
VOB
HubZone
SDB
SDVOB
Women-Owned Small Business
MBE Agency
WBE Agency
Non-Certified

Answer the Following Questions if the business is interested in DOT's Financial Assistance or Bonding Programs

Does the business currently hold a surety bond?

Yes
No

If not, has the business or a principal in the business held a surety bond in the past?

Yes
No

Has the business or a principal in the business filed for bankruptcy in the past?

Yes
No

Has a principal in the business had a prior felony conviction?

Yes
No

PART C - TYPE OF ASSISTANCE REQUESTED

Type of Assistance - Check All That Apply
Technical Assistance (accounting, planning, contract review, marketing, bidding and estimating, project management, financing, ect.)
Financial Assistance (DOT Short Term Lending Program or other financial assistance)
Bonding (DOT Bonding Education Program or other bonding assistance)

Please provide a brief narrative of the type of assistance the business is seeking (be specific):