Renaissance Client Intake Form
We thank you for applying for Renaissance's services and for sharing information about you and your business/business idea. Our goal is to help Bay Area entrepreneurs reach their financial and business goals. The information you provide gives us the information needed to:

1. Assess your entrepreneurial needs and support your progress.
2. Receive the financial support we need to provide free or affordable services to aspiring and established entrepreneurs like you.

All information will be kept confidential. We will not share this information with any other person, agency, or entity outside of Renaissance without your permission.

If you have any questions, please let us know. Thank you!
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Email *
What device are you using to access our online courses? *
Have you ever completed an online class? *
Have you ever used Zoom for online training? *
Have you ever used Google Classroom for online training?
Clear selection
First Name *
Last Name *
Address *
City *
State *
Zip Code *
Home Phone
Cell Phone *
1. How did you hear about Renaissance? *
Provide name of specific media (website, social media,) agency, person ororganization:
2. Did you consider options outside Renaissance when looking for business development services? *
Required
If “Yes”, why did you choose Renaissance instead of other organizations?
3. Gender *
4. Sexual orientation (optional):
Clear selection
5. What is your date of birth? *
(month/day/year)
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6, Are you Hispanic or Latina/o? *
7. Race: *
(check all that apply)
Required
8. Do you consider yourself an immigrant to the US? *
9. Do you have a disability? *
10. Veteran Status: *
11. Military Status: *
12. What is your highest level of education? *
13. What is your employment status? (check all that apply):           *
14. Are you a single parent?   *
15. Are you the head of household or main wage earner? *
16. Household Size: including yourself, your spouse/partner, and dependents *
How many people are in your household sharing income & expenses?
16.1 Number of children under 18 living in your household? *
17. Household Income: estimate your most recent annual household income from ALL sources and before taxes: *
$ _____for _____(yyyy) This information will be kept CONFIDENTIAL
18. Does anyone in your household (including you) receive public assistance (housing, food, disability, etc.)? *
This information will be kept CONFIDENTIAL
What is your income source? *
This information will be kept CONFIDENTIAL
Job Category *
Required
19. What is your business status? *
20. What business challenges are you currently facing? *
21. Business Name:
Enter your company name (if you already have one).
22. Describe your business or business idea: *
please be specific and include industry: e.g. restaurant, retail, etc.
23. Is your business making regular sales of your product or service?
Clear selection
24. When did your business start having regular sales (official business start date) or when do you intend to makeregular sales?
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25. Business Address:  
(Address, City, State, Zip Code)
25.1 Website:
25.2 Business Email:
25.3 Business Phone:
25.4 Social Media handles:
Facebook, Instagram, LinkedIn, TikTok, or other
26. What were your business sales/revenues last calendar year?
(estimates are OK)
27. Do you pay yourself a salary or pay bills or personal expenses from the business?
Clear selection
27.1 If “Yes”, how much did the business pay you last calendar year? (estimates are OK)
28. What is your business ownership structure (legal entity)? *
What percent of your business is owned by - Women:__________% Men:____________%
31. Do you have a DUNS number? *
A nine-digit number that identifies companies worldwide, called the Universal Data Numbering System. DUNS is a system recognized worldwide that was developed by Dun & Bradstreet (D&B) and that assigns a unique identification number to companies.
31.1 If “Yes”, please provide:
32. Do you have a business license? *
32.1 If “Yes”, issuing City/County:
33. How much do you work for this business? *
34. Does your business support any jobs (employees, contractors or business partners)? *
34.1 If “Yes”, provide the number of jobs that your business supports. Don’t include yourself. *
Today's date *
(Month, Day, Year)
MM
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Client Signature (print full name) *
Full name
Submit
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