ZWHJCOC SMALL BUSINESS TECHNICAL ASSISTANCEP ROGRAM Name * First Name Last Name Email Address * Phone Number * (###) ### #### Zipcode * County of Residence * Age * Gender * Male Femaile Non-binary Business Name * Business Website or Social Media http:// Which best describes your business stage? * Idea stage (no business income yet) Startup (0-3 years) Established (4+ years) I don't have a business Business Structure: * Sole Proprietor / DBA LLC Corporation Nonprofit Not yet registered Do you have an EIN (Employer Identification Number)? * Yes No Does your business sell a product, service or both? * Product Service Both What exactly do you sell or plan to sell? * What is your business' average gross monthly income? * No income yet Under $1,000/month $1,000-$5,000/month $5,000-$10,000/month Over $10,000/month Approximately how many products/services do you sell per month? * Do you have a bank account? (Click all that apply) * Business Checking Business Savings Personal Checking Personal Savings I don't have a bank account but I would like to open one How many of the following accounts do you have? * Cheking Savings I don't have an account but would like to open one How much money do you have saved? * What is your net worth? * use calculator here: https://www.ramseysolutions.com/retirement/net-worth-calculator?srsltid=AfmBOopDZp0WtevSaOsx_Pjb29AK5ZKGTf1iJeQksCpw1mPFlUC94PzU Have you opened a brokerage account? * No Yes Do you own any precious metals? (gold, silver, etc.) * No Yes Do you own any other assets? * None Business equipment or tools Vehicles Real estate Other What is your credit score? * Do you have any debt? * No Yes What types of debt do you have? (Click all that apply) * Credit Cards Student Loans Auto Loans Mortgage Personal Loans Other How much is your total debt? (not including your mortgage) * Have you applied for business funding or loans? * Yes - I was funded Yes - but I was not funded No - I haven't applied yet What are your current business goals for the next quarter? * What are your expectations from this program? * How did you hear about this program? * Referral Social Media Flyer/Event Organization/Nonprofit Other Would you be available for a 30-minute informational interview via phone or zoom? * Yes No I need more information Are you able to commit to completing assignments and working on your business during this program, even while working or managing other responsibilities? * Yes, I can commit No, not at this time Maybe, depends of the schedule Will you need access to our computer lab? * No Yes Thank you for your submission. — Zan Wesley Holmes Jr Community Outreach Center Team
