POC Small Business Network Web Intake Survey
1.
Please enter your name.
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First Name
Last Name
2.
Street address of your home
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3.
Zip code your home is located in.
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4.
Do you identify as Black and/or Latino?
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No Response
Yes
No
5.
If you would like to offer greater detail to your response above, how do you racially and/or ethnically identify?
6.
Has your business made at least one sale since it started?
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Yes
No
7.
What month and year did your business start? (enter in MM/YYYY format) Estimates are acceptable too.
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8.
What is the name of your business?
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9.
Street address of your business
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10.
Zip code your business is located in.
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11.
What is your email address?
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12.
What's the best phone number we can reach you at?
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13.
Generally, when is the best time to call you?
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14.
Let us know what is the best way to get in contact with you.
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Phone Call
Text
Email
Social Media
15.
If you selected Social Media for the previous question, what platform(s) are you/your business on? Under what name can we find you/it?
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