CIty of Atlanta Registration Form

1. Please enter your name. *

First Name	Last Name

2. What is your company's name?

3. What is your preferred email address to receive our email communications? *

4. What is your work phone number?

5. How did you hear about this program?

6. Please enter your website address.

7. What is your gender?

	Male
	Female

8. This program is sponsored by the City of Atlanta and EXCLUSIVELY for residents who live in Atlanta OR those currently managing a business in the City of Atlanta. What county do you live in? (Address verification is REQUIRED) * *

9. How did you originally learn of our organization?

10. This program is sponsored by the City of Atlanta and EXCLUSIVELY for residents who live in Atlanta OR those currently managing a business in the City of Atlanta. What county do you live in? (Address verification is REQUIRED) *

11. Is your company currently in business?

	Yes
	No

12. If you are in business, in what month and year did your business start? (enter in MM/YYYY format)

13. What is your annual household income?

	<$10K/year
	$10k-$19K/year
	$20K-$29K/year
	$30K-$39K/year
	$40K-$59K/year
	$60K-$74K/year
	$75K-$99K/year
	$100K+/year

14. The City of Atlanta REQUIRES that all participants submit proof of address AND income information in order to participate in this free program. Will you be willing to email address and income information to the program administrator in order to participate? *

Yes	No

15. Please provide a brief description of your business. *

16. How many people are living in your household with you?