Client Intake Form V.3
In order to obtain assistance from our center, please complete and submit this form. Once we receive your submission, someone will be in touch to schedule a business advising appointment at no cost to you.
1.
If a Business Advisor referred you to our services, please list his/her name here so that we can assign that person to you (if not, or if someone other than a Business Advisor referred you, please type "N/A" below).
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2.
Please enter your name.
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First Name
Last Name
3.
Please describe the type of small business assistance that you are requesting.
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4.
What email address would you like for us to use in order to communicate with you?
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5.
What is your cell phone number? There will be an opportunity to give your work number on the next page of this form.
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6.
What is your home number?
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7.
What is your residence's five-digit zip code?
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8.
In what city do you reside?
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9.
What is your home street address? Please do not include your city, state, or zip code here.
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10.
What is your birthday? (mm/dd/yyyy)
11.
What is your gender?
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Male
Female
12.
What is your race?
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Native American/Alaskan Native
Asian American
African American or Black
Native Hawaiian/Pacific Islander
White
13.
What is your ethnicity?
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Hispanic
Non-Hispanic
14.
What is your disability status?
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Not disabled
Disabled
15.
What is your current military status?
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On Active Duty
Veteran
Service Disabled Veteran
Member of National Guard
Member of the Reserve
Spouse of Military Member
No Military, Reserve, or National Guard Service
16.
How did you originally learn of our organization?
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No Response
Accountant
Attorney
Bank/Financial Institution
Civic Organization
Client/Word of Mouth
College/University
EDC
Expo/Chamber Event
Internet
Marketing Campaign
Marketing Extras
Mentor/Consultant
Miscellaneous
Newspaper or Magazine
Other Organization
Past Resource Partner
Radio
Resource Partner
SBDC
Speaking Engagement
Sponsor
Television
Training Seminar
Unknown
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