Gary Urban Entrepreneur Initiative Application for Assistance

Transcription

1 Gary Urban Entrepreneur Initiative Application for Assistance In order for us to provide you and your business with the help you need to succeed, please complete the following questions. Once we receive your information, we will contact you via within three business days with additional information. For your convenience, this is a fill-able form. To use it: 1) Save this document to your computer s hard drive, or external drive, if you prefer. 2) Type your responses into the fields provided for each answer. 3) your completed form to: JMOSELEY@CI.GARY.IN.US Please note: To use this form, you will need to have Adobe Reader installed on your computer. You can download a free copy here: Section I: Information About You 1. Last name: 2. First name: 3. Street address (no P.O. boxes): 4. City: 5. State: 6. Zip code: 7. Daytime telephone number: 8. Mailing address (if different from above): 9. City: 10. State:

2 11. Zip code: 12. Are you: Male Female 13. What is your age? Are you: African-American Asian-Pacific Islander Caucasian Hispanic Native American Other 15. What is the highest level of education you have attained? Less than high school graduate High school graduate or GED Some college Trade school graduate College (undergraduate degree) College (graduate degree) 16. Are you: Single Married Divorced Separated Widowed 17. Do you have children? Yes No 17a. If Yes to 17, how many children do you have? more than 8 17b. If Yes to 17, how many of your children are under the age of 18? more than What is your household s annual income? 19. Do you have military service? Yes No 19a. If Yes to 19, are you: Veteran Active duty Reserve National Guard

3 20. Are you starting a new business? Yes No If you answered No to 20, please complete Section II. If you answered Yes to 20, please skip to Section III. Section II: Information About Your Business 21. Business name: 22. Business street address (no P.O. boxes) 23. City: 24. State: 25. Zip code: 26. How long have you been in business? Years Months 27. What is the nature of your business (for example: daycare, catering, shoe store, etc.) 28. What was your business gross revenue last year? 29. Other than yourself, how many workers do you employ? more than 10 Section III: Information About Your Business Needs 30. What type(s) of business assistance are you requesting? (Please check all that apply.) Business start-up training Business consulting Business financing Five Plus Trax license

4 31. Have you sought assistance for your business in the past? Yes No 31a. If yes, to 31, which of the following have you contacted? (Please check all that apply.) U.S. Small Business Administration Northwest Indiana Small Business Development Center (Purdue-Calumet) SCORE (formerly Service Corps of Retired Executives) Bank, credit union or other business lender Angel group, venture capitalist or other type of investor Other Section IV: Certifications and Acknowledgements I understand that there is no guarantee that the assistance I receive through the Gary Small Business Center and / or any of its partners--including, but not limited to, the City of Gary, Gary Economic Development Corporation, and Gary Chamber of Commerce--will guarantee the success of my business; nor will said assistance guarantee approval of any application or other request for financing I might make. I understand that information pertaining to me, my business, and the assistance I receive through the Gary Small Business Center and / or any of its partners--including, but not limited to, the City of Gary, Gary Economic Development Corporation, and Gary Chamber of Commerce--might be shared with third parties for the purposes of evaluating and reporting the outcomes of the Gary Urban Entrepreneur Initiative, including the outcomes associated with my usage of any products and / or services provided to me through the Initiative. I understand that my address might be shared with third parties for purposes of advising me of activities, events, and / or products and / or services that might be of interest to me or my business, and that I will have the ability to opt-out should I no longer wish to receive said information delivered to me electronically. By submitting this Application either in-person or electronically, I am attesting that: 1) the information I have provided is truthful and accurate to the best of my knowledge; 2) I am the individual named in Items 1 and 2; 3) I currently reside within the Incorporated or Unincorporated City Limits of Gary, IN; 4) I am at least 18 years of age; and 5) I have read, understand, and agree to the information set forth in Section IV: Certifications and Acknowledgements. Signature (signed or typed) Date

5 Section V: For Initiative Office Use Only Census Tract: NAICS four-digit code: