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First Name*

Last Name*

Title*

Legal Name of Business*

If your business doesn't have an official name yet, please enter your First and Last name + Startup. For example: Jane Smith Startup

Address*

Street Address Address Line 2 (Suite #, Apartment #, etc) City State / Province / Region ZIP / Postal Code Country

Cell Phone:

Business Phone:*

Email:*

Website:

Please be sure to include https:// or http://

What would you like to see a business counselor about?*

Check all that apply

Currently in Business?*

Yes (existing business)

No (starting a new business)

Business Information

If the Answer is yes, when was the start date of the business?

Month & Year

What is the legal structure of your business?*

Percent owned by woman?*

Please enter a number less than or equal to 100.

Type of Business*

Choose primary category

Home-based business?*

Yes

Is it an online business?*

Yes

Are you currently exporting?*

Yes

Amount of your Gross Revenues/Sales related to exporting

Total No. of Full-Time Employees*

Total No. of Part-Time Employees*

For your most recent full business year, what were your full Gross Revenue/Sales?*

For your most recent full business year, what were your profit/loss?*

Demographic Information

Preferred Language*

Race:

Disability:

Yes

Prefer not to say

Veteran Status:

No military service

Veteran

Active Duty

Member of the Reserve

Member of the National Guard

Service Related Disabled

Military Spouse

Prefer not to say

Ethnicity:

Non-Hispanic or Latino/a

Hispanic or Latino/a

Prefer not to say

Gender Identify As:

Male

Female

Non-Binary

Prefer to self-describe

Prefer Not to Say

Other

Sexual Orientation:

Non-LGBTQ

LGBTQ

Prefer to Self-Describe

Prefer Not to Say

Other

Business Information

Demographic Information

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