October / November Classes Registration

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Capital Readiness Fall 2024 Program Upcoming Classes:

11/1 - Start-Up Success: Forming a Business from the Ground Up

Intake Form

This is a program funded through the Capital Readiness Program with the Minority Business Development Agency.

First Name *

Last Name *

Email *

Cell Phone Number *

Business Address *

City *

State *

Zip Code *

Do any of these designations apply to you? *

Membership in a group that has been subjected to racial or ethnic prejudice or cultural bias within American society

Discrimination due to Gender

Discrimination due to Sexual orientation

Discrimination due to Religion

Discrimination due to Limited English proficiency

I am a Veteran

I have a Disability

I'm a Member in a federally or state-recognized Indian Tribe

I live in a U.S. Territory

I live in a rural community

None of the above

Required

Does your Business Focus on Exports? *

Yes

If yes, what is the planned or actual export destination?

What is your Ethnicity? Select all that apply: *

American Indian or Alaska Native - Write In

Asian - Chinese

Asian - Asian Indian

Asian - Filipino

Asian - Vietnamese

Asian - Korean

Asian - Japanese

Asian - Write in

Black or African American – African American

Black or African American – Jamaican

Black or African American – Haitian

Black or African American – Nigerian

Black or African American – Ethiopian

Black or African American – Somali

Black or African American – Write in

Hispanic or Latino – Mexican

Hispanic or Latino – Puerto Rican

Hispanic or Latino – Salvadoran

Hispanic or Latino – Cuban

Hispanic or Latino – Dominican

Hispanic or Latino – Guatemalan

Hispanic or Latino – Write in

Middle Eastern or North African – Lebanese

Middle Eastern or North African – Iranian

Middle Eastern or North African – Egyptian

Middle Eastern or North African – Syrian

Middle Eastern or North African – Iraqi

Middle Eastern or North African – Israeli

Middle Eastern or North African – Write in

Native Hawaiian or Pacific Islander – Native Hawaiian

Native Hawaiian or Pacific Islander – Samoan

Native Hawaiian or Pacific Islander – Chamorro

Native Hawaiian or Pacific Islander – Tongan

Native Hawaiian or Pacific Islander – Fijian

Native Hawaiian or Pacific Islander – Marshallese

Native Hawaiian or Pacific Islander – Write in

White – English

White – German

White – Irish

White – Italian

White – Polish

White – Scottish

Required

If you selected "write in" please specify here:

Gender *

Sexual Orientation *

Are you the owner of the business? *

Yes

Other

If "other" - what is your role with the business?

Business Name: - Type N/A if you don't have a business get *

What is the legal structure of your business? *

Sole Proprietorship

Partnership

S-Corporation

C-Corporation

Limited Liability Corporation (LLC)

Limited Partnership (LP)

# of Full-Time employees (including owner): *

# of Part-Time employees: (includes 1099 or seasonal) *

Does this business focus on exports?
*

Yes

If yes, what is the planned or actual export destination?

Industry - (by NAICS code)

US Census provides an online reference for NAICS codes https://www.census.gov/naics/?58967?yearbck=2022

How did you hear about this event? If you were referred by an organization please write the name below. *

Submit

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