State:*

ZIP (with +4 if known):*

Phone*:

FAX*:

e-Mail Address:*

Web Site Address :

Business Information:

Business Structure*: Select Org.Type Sole Proprietorship Corporation LLC S-Corperation Partnership Non-Profit

Month/Year your business started?* (MO/YEAR): Type NA or None if not yet started.

Number of Employees -   Full-Time*:
Part-Time*: If none put 0.

Which one of the following best describes your businesses revenue projections for the coming year if known?*

Select $ Revenue Less than $10,000 $10,000+ $50,000+ $100,000+ $500,000+ $1,000,000+ Over 1 Million Can't even guess

Type of Business Description: (Choose best category.)*:   Select Business Description Accomodation/Food Service Administrative Support Agriculture/Forestry/Fishing & Hunting Arts/Entertainment/Recreation Construction Finance/Insurance Health Care/Social Assistance Information Management of Companies/Enterprises Manufacturing Mining Professional/Scientific/Technical Services Public Administration Real Estate/Rental/Leasing Retail Trade Utilities Wholesale Trade

NAICS or SIC Code (If known.):

Does your business have a formal business plan?* Select One Yes No Partial or Outdated

Does your business plan include a cash flow analysis?* Select One Yes No

The following questions are to determine if you might be in a classification that might influence your potential for various types of grants and funding:

Race: Select One Asian Black/African Native American/Alaska Native White Ethnicity: Select One Hispanic Origin Non-Hispanic Origin

Gender*: Select One Male Female

Do you consider yourself a person with a disability?*: Select Yes or No Yes No

Veteran/Military Status*: Select One Member of the Reserve/Nat'l Guard On Active Duty Reg. Military Retired Military Honorably Discharged Not Applicable

Business Needs Assessment - Checklist: (Feel free to complete the areas you feel that may apply to you.)

Please take a moment to complete this assessment. It is designed to help you identify your needs and concerns and allows us to provide you with more customized and expeditious assistance.

Financial Management: (Select up to three areas that presently concern or interest you.)

Sales/Marketing: (Select up to three areas that presently concern or interest you.)

General Management: (Select up to three areas that presently concern or interest you.)

Legal Issues: (Select up to three areas that presently concern or interest you.)

Human Resource Issues: (Select up to three areas that presently concern or interest you.)

Special Topics: (Select up to three areas that presently concern or interest you.)

Please review selections to ensure all required fields, marked with an *, have been selected or completed before selecting the submit button below.