strengthening businesses and communities, one entrepreneur at a time

Transcription

1 BACKGROUND Micro Enterprise Services of Oregon (MESO) seeks to provide technical and financial assistance to low income & small existing and new businesses whose owners reside and/or have businesses in Portland. QUALIFICATIONS Answer the following questions. If you answered YES to all three, you may qualify to participate in the MESO program. Do you need technical assistance to improve your existing business? Is your business located in Portland OR do you live in Portland? Is your income 50% of Median Income Percentage? (see chart below) APPLICATION PROCESS If you answered yes to the questions above, please complete the following application and include all required attachments. We will notify you within 3 weeks of receipt of the application for more information, an interview, or an acceptance into our program. CHECKLIST Return to MESO: Completed Application Copy of Current Tax Forms $25 membership fee/year FY 2011 Median Income for a Family of Four (Portland, OR): $72,000 Household Size 50% 55% 60% 65% 80% 1 25,200 27,720 30,240 32,760 40, ,800 31,680 34,560 37,440 46, ,400 35,640 38,880 42,120 51, ,000 39,600 43,200 46,800 57, ,900 42,790 46,680 50,570 62, ,800 45,980 50,160 54,340 66, ,650 49,115 53,580 58,045 71, ,550 52,305 57,060 61,815 76,050 1

2 strengthening businesses and communities, GENERAL INFORMATION First Name: Last Name: Social Security Number: Date of Birth: Home Address: City: Zip: Mailing Address: (write same if home) City: Zip: Phone: Alternate Phone: EDUCATION/TRAINING HISTORY Did you graduate from high school? Yes No Have you receive your GED? Yes No Not Applicable Name of School Location (City/State) Course of Study Degree or Certificate Received High School College Trade School INCOME & DEMOGRAPHIC VERIFICATION Because the MESO program receives public funds to cover part of our operating costs, we are required to collect income and demographic information on our participants. We appreciate your willingness to assist us by completing the following for our records. Annual Gross Business Receipts: Net Business Income: Value of Business: # Paid Full-Time Employees (include self): # Paid Part-Time Employees (include self): Annual Family Income (Gross): Family Size: MARITAL STATUS: Single Married Domestic Partner GENDER: Male Female HOUSING: (please mark ALL that applies) Own Rent Head of Household Transitional Housing Homeless DISABILITY: Do you have a disability? Yes No IF YES, has this been a barrier to work? Yes No INSURANCE: (please mark ONE) Uninsured Self-Paid Public-Paid Employer-Paid U.S. CITIZEN: Yes No REGISTERED FOR SELECTIVE SERVICE (MALES ONLY): Yes No Mark all that applies: Asian or Pacific Islander Hispanic/Latino(a) American Indian/Alaskan Native Caucasian (not of Hispanic origin) African-American/Black African European/Eastern European Native Hawaiian/Pacific Islander I hereby certify to the best of my knowledge that the information given herein is true and accurate and I understand that the information I have supplied is subject to verification. 2

3 BUSINESS INFORMATION Business Name: Federal Tax ID Number: Business Address: City: State: Zip: Phone: Alternate Phone: Website: BUSINESS PROPOSAL 1. Describe your business idea (include your vision and mission) 2. What are your business goals? 3. Have you registered your business name with the Oregon Corporation Division? Yes No I don t know 4. Have you set your business up as a Sole proprietorship Partnership LLC Corporation I don t know 5. Describe your experience with this type of business 6. Describe the reasons for wanting to have your own business 7. Describe the reasons you think you will be a successful business owner 3

4 8. Will this business supplement your income or be the sole source of income? 9. How long have you operated this business? 10. Describe your financial recordkeeping system. How are you currently keeping track of your business income/expenses? 11. Describe your marketing strategy. How will you attract people to your business? 12. List the type of technology, software, and equipment you use to run your business. Desktop Computer Laptop Printer Scanner Internet Microsoft Office QuickBooks/Peachtree, etc, Please List: 13. Describe ways MESO could help you succeed in your business venture. I hereby certify to the best of my knowledge that the information given herein is true and accurate and I understand that the information I have supplied is subject to verification. 4

5 FINANCIAL BACKGROUND 1. List all outstanding loans and their current amounts. 2. Would you consider your credit to be (mark one) Excellent Good Fair Poor 3. Have you ever declared bankruptcy? Yes No If yes, which year did you declare bankruptcy? What was the reason for declaring bankruptcy? 4. Do you owe any back taxes, judgments or garnishments? Yes No If yes, who do you owe and what are the amounts of each? 5. Describe other types of debt and the amounts (i.e. from friends/family/etc.) 6. Do you have financial or any other assistance with your business? Yes No If yes, please describe FINANCIAL BACKGROUND CHECK To determine eligibility for any financial assistance provided by MESO, we require access to information about your financial background and financial credit. MESO has my permission to access information and require a credit report on my financial background. Yes No 5

6 PERSONAL FINANCIAL STATEMENT Name: ASSETS Amount I/J LIABILITIES Amount I/J Checking Notes Payable to Banks Savings Bank Charge Card Certificates Bank Cards Cash Open or Revolving Accounts & Bills Payable Stocks/Bonds Listed Alimony, Child Support, Etc Stocks/Bonds Unlisted Bills Payable Life Insurance (Cash Purchase Contracts & Value) Installment Loans Profit Share Plan-Vested Installments Income Tax Owing Income Tax-Refund Due Property Tax Owing Tax Refund Taxes Owing Accounts/Contracts/Notes Receivable Secured Loans Real Estate I Unsecured Loans Real Estate II Real Estate Loan I Car I: Yr- Make- Real Estate Loan II Car II: Yr- Make- Liabilities Equipment Personal Property Patents, Royalties, Etc TOTAL ASSETS $ TOTAL LIABILITIES $ NET WORTH (total assets minus total liabilities) $ Mo. Payments SIGNATURE By signing below, I attest that all information in the Personal Income Statement is true and accurate to the best of my knowledge. 6

7 PERSONAL INCOME STATEMENT Name: INCOME MONTHLY ANNUAL Current Salary Current Salary (spouse) Current Business Net Income Pension Income Alimony/Child Support (disclosure of this type of income is voluntary) TOTAL INCOME EXPENSES MONTHLY ANNUAL House Payment Rent Payment Rental Property Credit Cards Auto Payment Auto Insurance Utilities Installment Debt Food/Clothing Medical/Dental Insurance Medical/Dental Expense Alimony/Child Support TOTAL EXPENSES SIGNATURE By signing below, I attest that all information in the Personal Income Statement is true and accurate to the best of my knowledge. 7

8 EMPLOYMENT HISTORY Current or Last Employer Phone Address Immediate Supervisor & Title May we contact for reference? Yes Yes, but notify me first No Job Title Description of job duties Start Full Time Part-Time Salary/hourly rate End If Part-Time, number of hours per week: Reason for leaving Current or Last Employer Phone Address Immediate Supervisor & Title May we contact for reference? Yes Yes, but notify me first No Job Title Description of job duties Start Full Time Part-Time Salary/hourly rate End If Part-Time, number of hours per week: Reason for leaving RELEASE OF INFORMATION Name: I understand that the Micro Enterprise Services of Oregon (MESO) program is assisting me in creating and/or growing my small business. I authorize them to obtain copies of my working case file from other agencies for the purpose of continuing my services without interruption and verifying future business status. In the event that I am also receiving services funded by other programs, I authorize the above-mentioned organization to share my information with these other organizations for the purpose of collaborative case management. I have enrolled in programs at the following organizations: Child Care Improvement Project Hacienda CDC Hispanic Metropolitan Chamber Housing Development Center Mercy Corps, NW OAME PSU Small Business Outreach Trillium Artisans All information regarding my records will be held confidential. I understand that the above mentioned organization will retain the right to review historical files if necessary. I understand that this authorization is voluntary, and I may deny this authorization without impacting the services I receive from MESO. 8

9 OTHER SERVICES Are you receiving services from any other agencies/institutions/consultants? Yes No If yes, please list: CRIMINAL BACKGROUND HISTORY CHECK To determine eligibility for MESO, we need access to information about your criminal background history. The opinion of your parole officer as well as the criminal justice system will assist us in determining eligibility. All applicants will be screened equally. Have you been convicted of any crime Yes No Were you incarcerated? Yes No If yes, what facility? Type of offense I agree to a criminal background history check. Yes No You may contact my parole officer. Yes No Not Applicable You may contact individuals from the facility of my detention. Yes No Not Applicable PROFESSIONAL REFERENCES List 3 references (colleagues, employers, vendors, & business associates). Name Relationship Phone Number STATEMENT OF AGREEMENT AND SIGNATURE Please read the following statements, check off, initial, and sign below: I understand that I am making a three-year commitment to remain in contact with program staff for ongoing support and business development services. I will submit actual or estimated quarterly and annual gross sales information to program staff, and I will provide a copy of my tax return (that is relevant to determining business income) for the third year, at a minimum. Initials: I hereby certify to the best of my knowledge that the information given herein is true and accurate and I understand that the information I have supplied is subject to verification. Initials: 9