Request for information INTAKE DATE* Full Name* FIRST NAME MIDDLE INITIAL LAST NAME Address* Street ADDRESS Street ADDRESS 2 CITY STATE ZIP E-Mail* TELEPHONE (HOME)* TELEPHONE (CELL)* Fax* IMMIGRATION STATUS* U.S CITIZEN PERMANENT RESIDENT OTHER Other: HOW DID YOU HEAR ABOUT US* Are you currently in business?* Yes No Date Opened: Pre-Start Up Startup Existing Business Name or Business Idea* Type of Business* RETAIL WHOLESALE SERVICE CONSTRUCTION MANUFACTURING OTHER What type of business assistance do you need? Check all that apply.* Training Financing Counseling I don’t know; need to talk to someone first Amount Requested* $ Gender* MALE FEMALE Do you have a disability* Yes No Ethnicity* HISPANIC ASIAN WHITE BLACK NATIVE AMERICAN OTHER Women owned business?* Yes No Rural Urban NAICS CODE Biz Gross Annual Sales* $ Organization Structure* Sole Proprietor Partnership Corporation Limited Liability Corporation Joint Venture Non Profit Corporation Enter Code