Applicant Information First Name * Last Name * Address Info Address * City * State * Zip * Contact Info Day Phone * Evening Phone * This can be the same as your day phone. Email Address * Demographics Race/Ethnic Background * African American Asian American Oromo Ethiopian Liberian Somali Hispanic Kenyan Other... Race/Ethnic Background Other... Gender * Male Female Other... Gender Other... Marital Status * Single Married Divorced Widowed Veteran Status Non Veteran Vietname Era Veteran Other... Veteran Status Other... Age Under 20 20-29 30-39 40-49 50-59 60 or over Are you currently a refugee or asylee? * Yes No If yes, you and/or our organization may be eligible for financing from a special source of funds. I have a partner or co-applicant * Yes No Partner or Co-Applicant First Name * Last Name * Address Info Address * City * State * Zip * Contact Info Day Phone * Evening Phone * This can be the same as your day phone. Email Address * Demographics Race/Ethnic Background * African American Asian American Oromo Ethiopian Liberian Somali Hispanic Kenyan Other... Race/Ethnic Background Other... Gender * Male Female Other... Gender Other... Marital Status * Single Married Divorced Widowed Veteran Status Non Veteran Vietname Era Veteran Other... Veteran Status Other... Age Under 20 20-29 30-39 40-49 50-59 60 or over Are you currently a refugee or asylee? * Yes No If yes, you and/or our organization may be eligible for financing from a special source of funds. Please select the option that most reflects your educational background. Applicant Education Educational Level - Select -Elementary SchoolHigh SchoolGEDTechnical SchoolUndergraduate DegreeGraduate Degree Partner Education Educational Level - Select -Elementary SchoolHigh SchoolGEDTechnical SchoolUndergraduate DegreeGraduate Degree What do you rely on as your PRIMARY source of HOUSEHOLD income? Applicant Household Income Income * - Select -Self-Employed (Full Time)Self-Employed (Part Time)Full-Time JobPart-Time JobSpouse or Partner IncomeSavings or InvestmentsAlimony or Child SupportPublic AssistanceUnemploymentSocial SecurityDisabilityOther... Income Other... Do you receive welfare benefits? * Yes No Partner Household Income Income * - Select -Self-Employed (Full Time)Self-Employed (Part Time)Full-Time JobPart-Time JobSpouse or Partner IncomeSavings or InvestmentsAlimony or Child SupportPublic AssistanceUnemploymentSocial SecurityDisabilityOther... Income Other... Does the partner receive welfare benefits? * Yes No Have you ever received business training * - Select -Yes, I started this program, but did not finishYes, from another organizationNo Where did you receive your training? Do you have experience managing or operating the type of business you're interested in? * Yes No Describe your experience What type of job do you have now? * Tell us about your business Please answer the following questions as completely as you can. Have you opened your business yet? * Yes, Full-Time (35 hours/week or more) Yes, Part-time (less than 35 hours/week) No Name of Business (official or unofficial) * Please describe your business or business idea * Why do you want to start or expand your own business? * Do you expect your business to provide: * Primary Income Secondary Income How much money do you have to put into your business? $ Not Open Business Where do you plan to locate your business? Provide the address where you plan to open the business. If you don't have an address yet, you may enter a general location. Do you need help finding a location? Yes No Open Business Where is your business located? In Home Commercial Location What is the business Address and Name? Business Name Business Phone Number Street Address City State Zip What type of business do you operate? - None -Service to IndividualsService to BusinessesRetail or TradeWholesaleManufacturing How long has your business been in operation? - Select -Six months or lessSix months to one yearOne to three yearsMore than 3 years Year first sale was made? Your Employees How many full-time employees do you have? How many part-time employees do you have? How many employees are family members? How many hours do you work at your business each week? Do you take an owner's draw (salary)? Yes No How much do you draw per year? $ How did you find out about this program? CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
