Client Intake |

In order to continue providing services for our community, our funders require us to collect detailed demographic information on all of our clients. In order to become one of our clients, please fill out the form below. Please note that it is 4 pages long, and we anticipate it taking about ten minutes to complete. We apologize for the length: these are the questions we are required to ask in order to keep receiving money in order to offer these services for free to our community.

We will not sell or distribute this information to anyone. It will only be shared with our funders.

Thank you for taking the time to fill out the form.

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Step 1 of 4

Name(Required)

First Last

Email(Required)

Phone Number(Required)

Address(Required)

Street Address City State ZIP Code

Demographic Information

Sex(Required)

Race(Required)

Type of Asian:(Required)

Type of Pacific Islander(Required)

Self-Describe Race(Required)

Highest Level of Education(Required)

Ethnicity(Required)

Military Status(Required)

What branch of the military?(Required)

Do you consider yourself a person with a disability?(Required)

Are you a dislocated worker?(Required)

A dislocated worker is someone who has lost their job through no fault of their own, typically due to circumstances like a plant closing, mass layoff, or a shift in the industry that makes their skills obsolete. They are generally eligible for unemployment benefits and unlikely to return to their previous industry or occupation.

How many people (including yourself) live in your household?(Required)

Please enter a number greater than or equal to 1.

What is your household income?(Required)

If your household has no income, please choose the “$0 to $15,000” option.

Birthdate(Required)

Employment and Business Information

Employment Status(Required)

What is the name of your current employer? (If none, put "none." If self-employed, put "self-employed")(Required)

Most Recent Employment Start Date:(Required)

Most Recent Employment End Date (If Applicable):

If you left the job, what was the reason?

Regarding employment, please select:

Are you currently in business?(Required)

Company/Business Name(Required)

Type of Business(Required)

If you said "Other," please describe your industry(Required)

In 2 to 3 sentences, briefly describe your business(Required)

Stage of business(Required)

Please select which describes you best(Required)

If your business has already started, enter your business start date. An estimate is fine.(Required)

If your business has already made sales, enter the date you made your first dollar. An estimate is fine.

Do you have a business plan?(Required)

Business facility(Required)

Income generated by your business at this time is your:(Required)

How many FT + PT employees do they have(Required)

Please enter a number greater than or equal to 0.

Gross Revenues/Sales $ For most recent FULL Business Year(Required)

Please enter a number greater than or equal to 0.

If you have no sales, put “0”

Most Recent Full Business Year Part-Time Employee count(Required)

Please enter a number greater than or equal to 0.

If you have no employees, put “0.” Do not count yourself as an employee.

Most Recent Full Business Year Full-Time Employee count(Required)

Please enter a number greater than or equal to 0.

If you have no employees, put “0.” Do not count yourself as an employee.

MWBE certification status(Required)

MWBE Application Date(Required)

Please answer this to the best of your ability. If you do not know, write “I Don’t Know.” If this does not apply to you, write “N/A.”

MWBE Certified Date(Required)

Please answer this to the best of your ability. If you do not know, write “I Don’t Know.” If this does not apply to you, write “N/A.”

MWBE Rejected Date(Required)

Please answer this to the best of your ability. If you do not know, write “I Don’t Know.” If this does not apply to you, write “N/A.”

# of owners(Required)

Please enter a number greater than or equal to 0.

What percentage of your business is owned by a woman?(Required)

Please enter a number from 0 to 100.

Legal Entity(Required)

If you said "Other," please describe your legal entity(Required)

Do you conduct business online?(Required)

Are you 8(a) certified?(Required)

How many employees do you have, including yourself?(Required)

Please enter a number greater than or equal to 0.

Business Gross Revenue for the last year(Required)

Please enter a number greater than or equal to 0.

Are you currently exporting?(Required)

What is your business revenue amount related to exported?(Required)

Please enter a number greater than or equal to 0.

What number of your employees engage in exporting?(Required)

Please enter a number greater than or equal to 1.

What countries/territories do you export to?(Required)

If you selected "other," where do you export to?(Required)

How did you hear about us?(Required)

If you selected "other," how did you hear about us?(Required)

If you found out about us from a website, please list the website

What type of help do you need for your business?(Required)

If you selected "other," what help do you need help with?(Required)

I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA Resource Partner services. I permit SBA or its agent the use of my name and address for SBA surveys and information mailings regarding SBA products and services(Required)

By accepting this agreement I grant permission for QEDC to contact me regarding my business and its current status. I understand that any information disclosed will be held in strict confidence. (SBA will not provide your personal information to commercial entities.) I authorize SBA to furnish relevant information to the assigned management counselor(s). I further understand that the counselor(s) agrees not to: 1) recommend goods or services from sources in which he/she has an interest, and 2) accept fees or commissions developing from this counseling relationship. In consideration of the counselor(s) furnishing management or technical assistance, I waive all claims against SBA personnel, and that of its Resource Partners and host organizations, arising from this assistance. Please note: the estimated burden for completing this form is 5 minutes. You are not required to respond to any collection information unless it displaces a current valid OMB approval number. Comments on the burden should be sent to: U.S. Small Business Administration, 409 3rd Street, SW Washington DC 20416 and to: Desk Office SBA, Office of Management and Budget, New Executive Office Building, Room 10202, Washington D.C., 20503. OMB Approval (3245-0324). PLEASE DO NOT SEND TO OMB. Please mark """"yes"""" to verify that you agree to the terms above."(Required)

Yes

Would you like to be added to our newsletter to receive updates about future events?(Required)

Yes

Please certify that you have read and understood the above by writing your full name in the field here to serve as your electronic signature:(Required)

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