Intake Form

Race (mark one or more)
American IndianAlaska NativeAsianBlack or African AmericaNative Hawaiian or Other Pacific IslanderWhiteOther
Ethnicity:
Hispanic or LatinoNot Hispanic or LatinoOther
Gender:
MaleFemaleNon-binaryOther
Sexual Orientation:
LGBTQNot LGBTQOther
Do you consider yourself a person with a disability?:
YesNo
Military Status:
No military serviceService Disabled VeteranActive DutySpouse of Military Member
Are you currently in business?:
YesNo
(if no, skip questions 1-13)

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1. Name of Business 2. Taxpayer ID #
Is this a social security number?:
YesNo
3. Type of Business
MiningUtilitiesInformationConstructionRetail TradeManufacturingFinance & InsuranceWholesalePublic AdministrationEducational ServicesReal Estate & Rental & LeasingHealth Care & Social AssistanceAccommodation & Food ServiceArtsEntertainment & RecreationTransportation & WarehousingProfessionalScientific & Technical ServicesManagement of Companies & EnterprisesAgricultureForestryFishing & HousingAdministrative & SupportWaste Management & Remediation ServicesOther services (except Public Administration)
4. Business Ownership: What percentage of your business is male/female owned? 5. Date Business Started 6. Legal Entity:
Sole ProprietorCorporationS-CorporationLLCPartnershipOther
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:
UrbanRural
11. Are you requesting assistance in English? :
YesNo

12.Nature of Assistance Sought:
Paycheck Protection Loan/ForgivenessCovid Economic Injury Disaster LoanRestaurant Revitalization FundShuttered Venues GrantOther SBA Disaster Loans7(a) loan504 loanMicroloanExport LoanOther LoanState/local grantOther grantSBA Contracting CertificationAssistance Starting a BusinessOther
13. What is dollar amount of loan/grant sought?

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Have you applied for or received any SBA services in last 5 years?:
YesNo
If yes, which program(s) (check all that apply):
Paycheck Protection Loan/ForgivenessCovid Economic Injury Disaster LoanRestaurant Revitalization FundShuttered Venues GrantOther SBA Disaster LoansMicroloan7(a) or 504 guaranteed loan8(a) CertificationOther Contracting CertificationOther

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/preplanningBusiness PlanBusiness Financing/Capital SourcesCovid Financing ProgramsInternational TradeeCommerceBusiness Financials/Cash FlowCredit CounselingGovernment ContractingDisaster Preparedness/RecoveryBusiness OperationsManagementMarketingOther
Participating Partners:
SBA District OfficeSBDCSCOREWBCVBOCOther