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In order to continue providing services for our community, our funders require us to collect detailed demographic information on all of our clients. We will not sell or distribute this information to anyone. Please fill out the questions below and hit submit when completed.

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Name(Required)

First Last

Email(Required)

Phone Number(Required)

I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA Resource Partner services. I permit SBA or its agent the use of my name and address for SBA surveys and information mailings regarding SBA products and services(Required)

Address(Required)

Street Address City State ZIP Code

Country/Territory(Required)

If you selected "Other," what country/territory do you live in?(Required)

County(Required)

Gender(Required)

Self-Describe Gender(Required)

Race(Required)

Self-Describe Race(Required)

Ethnicity(Required)

Sexual Orientation(Required)

Self-Describe Sexual Orientation(Required)

Military Status(Required)

What branch of the military?(Required)

Do you consider yourself a person with a disability?(Required)

Place of Birth(Required)

If you selected other, what country/territory were you born in?(Required)

How many people (including yourself) live in your household?(Required)

Please enter a number greater than or equal to 1.

What is your total household income? (It's fine to estimate. If you have no income, put "0")(Required)

Please enter a number greater than or equal to 0.

How did you hear about us?(Required)

If you selected "other," how did you hear about us?(Required)

If you found out about us from a website, please list the website

Birthdate(Required)

Age(Required)

What type of help do you need for your business?(Required)

If you selected "other," what help do you need help with?(Required)

Please check all that apply:(Required)

Are you currently enrolled In Secondary School or Equivalency Program?

Do you have a HS diploma or High School Equivalency?

Postsecondary Certification, License, or Educational Certificate (Non-Degree)?

Attended College?

Completed 1 or More Years of Postsecondary Education?

Associate degree?

Bachelor’s degree or Equivalent?

Advanced Degree Beyond Bachelor’s Degree?

None

If you did not complete high school, what was your last grade completed?(Required)

Employment Status(Required)

What is the name of your current employer? (If none, put "none." If self-employed, put "self-employed")(Required)

What was/is your job title and duties? (If none, put "none." If self-employed, put "self-employed")(Required)

Most Recent Employment Start Date:(Required)

Most Recent Employment End Date (If Applicable):

If you left the job, what was the reason?

Regarding employment, please select:

Are you currently in business?(Required)

Company/Business Name(Required)

Type of Business(Required)

If you said "Other," please describe your industry(Required)

In 2 to 3 sentences, briefly describe your business(Required)

Stage of business(Required)

If your business has already started, enter your business start date. An estimate is fine.(Required)

Do you have a business plan?(Required)

Business facility(Required)

Income generated by your business at this time is your:(Required)

How many FT + PT employees do they have(Required)

Please enter a number greater than or equal to 0.

MWBE certification status(Required)

# of owners(Required)

Please enter a number greater than or equal to 0.

What percentage of your business is owned by a woman?(Required)

Please enter a number from 0 to 100.

What percentage of your business is owned by a racial or ethnic minority?(Required)

Please enter a number from 0 to 100.

Legal Entity(Required)

If you said "Other," please describe your legal entity(Required)

Do you conduct business online?(Required)

Are you 8(a) certified?(Required)

How many employees do you have, including yourself?(Required)

Please enter a number greater than or equal to 0.

Business Gross Revenue for the last year(Required)

Please enter a number greater than or equal to 0.

Are you currently exporting?(Required)

What is your business revenue amount related to exported?(Required)

Please enter a number greater than or equal to 0.

What number of your employees engage in exporting?(Required)

Please enter a number greater than or equal to 1.

What countries/territories do you export to?(Required)

If you selected "other," where do you export to?(Required)

Would you like to be added to our newsletter to receive updates about future events?(Required)

Please write today's date(Required)

By accepting this agreement I grant permission for QEDC to contact me regarding my business and its current status. I understand that any information disclosed will be held in strict confidence. (SBA will not provide your personal information to commercial entities.) I authorize SBA to furnish relevant information to the assigned management counselor(s). I further understand that the counselor(s) agrees not to: 1) recommend goods or services from sources in which he/she has an interest, and 2) accept fees or commissions developing from this counseling relationship. In consideration of the counselor(s) furnishing management or technical assistance, I waive all claims against SBA personnel, and that of its Resource Partners and host organizations, arising from this assistance. Please note: the estimated burden for completing this form is 5 minutes. You are not required to respond to any collection information unless it displaces a current valid OMB approval number. Comments on the burden should be sent to: U.S. Small Business Administration, 409 3rd Street, SW Washington DC 20416 and to: Desk Office SBA, Office of Management and Budget, New Executive Office Building, Room 10202, Washington D.C., 20503. OMB Approval (3245-0324). PLEASE DO NOT SEND TO OMB. Please mark """"yes"""" to verify that you agree to the terms above."(Required)

Yes

Please certify that you have read and understood the above by writing your full name in the field here to serve as your electronic signature:(Required)

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