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Intake Form
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Intake Form
1
.
Part I
2
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Part II- Business Information
3
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Part III – Business Advisor/ Mentor
4
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Part IV – Training Record
Race (mark one or more)
American Indian
Alaska Native
Asian
Black or African America
Native Hawaiian or Other Pacific Islander
White
Other
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Other
Gender:
Male
Female
Non-binary
Other
Sexual Orientation:
LGBTQ
Not LGBTQ
Other
Do you consider yourself a person with a disability?:
Yes
No
Military Status:
No military service
Service Disabled Veteran
Active Duty
Spouse of Military Member
Are you currently in business?:
Yes
No
(if no, skip questions 1-13)
1. Name of Business
2. Taxpayer ID #
Is this a social security number?:
Yes
No
3. Type of Business
Mining
Utilities
Information
Construction
Retail Trade
Manufacturing
Finance & Insurance
Wholesale
Public Administration
Educational Services
Real Estate & Rental & Leasing
Health Care & Social Assistance
Accommodation & Food Service
Arts
Entertainment & Recreation
Transportation & Warehousing
Professional
Scientific & Technical Services
Management of Companies & Enterprises
Agriculture
Forestry
Fishing & Housing
Administrative & Support
Waste Management & Remediation Services
Other services (except Public Administration)
4. Business Ownership: What percentage of your business is male/female owned?
5. Date Business Started
6. Legal Entity:
Sole Proprietor
Corporation
S-Corporation
LLC
Partnership
Other
7. Total Number of Employees
8. For your most recent business year list
9. Do you conduct business in a language other than English?
10. Location:
Urban
Rural
11. Are you requesting assistance in English? :
Yes
No
12.Nature of Assistance Sought:
Paycheck Protection Loan/Forgiveness
Covid Economic Injury Disaster Loan
Restaurant Revitalization Fund
Shuttered Venues Grant
Other SBA Disaster Loans
7(a) loan
504 loan
Microloan
Export Loan
Other Loan
State/local grant
Other grant
SBA Contracting Certification
Assistance Starting a Business
Other
13. What is dollar amount of loan/grant sought?
Have you applied for or received any SBA services in last 5 years?:
Yes
No
If yes, which program(s) (check all that apply):
Paycheck Protection Loan/Forgiveness
Covid Economic Injury Disaster Loan
Restaurant Revitalization Fund
Shuttered Venues Grant
Other SBA Disaster Loans
Microloan
7(a) or 504 guaranteed loan
8(a) Certification
Other Contracting Certification
Other
Information is provided by grantee
Total number Trained: include subtotals for Currently in Business, Not Yet in Business, People with Disabilities, Veterans, Women, LGBTQ, Race (American Indian or Alaska Native, Asian, Black or African America, Native Hawaiian or Other Pacific Islander, White), Ethnicity (Hispanic or Latino, not Hispanic or Latino)
Training Topic:
Business start-up/preplanning
Business Plan
Business Financing/Capital Sources
Covid Financing Programs
International Trade
eCommerce
Business Financials/Cash Flow
Credit Counseling
Government Contracting
Disaster Preparedness/Recovery
Business Operations
Management
Marketing
Other
Participating Partners:
SBA District Office
SBDC
SCORE
WBC
VBOC
Other
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