INTAKE FORM FOR SOUTHEAST CENTER FOR COOPERATIVE DEVELOPMENT
Please fill out the following intake application. You will be contacted by the Southeast Center for Cooperative Development to set up an appointment with one of our staff to discuss your needs. Thank you for your interest in working with us!
Sign in to Google to save your progress. Learn more
Email *
First and Last Name *
Cell phone number *
Address *
Street or P.O. Box, City, State and Zip Code
Which category describes you best? (Please select all that apply.) *
Gender: How do you identify?
Clear selection
What is your age range? *
What is your occupation? *
What is your employment status? *
What is your annual income level? *
This income supports ... (Please check all that apply.) *
Required
Have you been previously incarcerated? (This will not exclude you from any type of technical assistance or support. We are interested in working with people who have been marginalized from entrepreneurship and/or financing.) *
Are you receiving public assistance? *
Have you previously owned a business? *
Tell us about your cooperative business idea: describe your business model. What kind of services/products does/will your business provide?If you have an existing business, let us know more about it. *
What kind of business is it? Ex. restaurant, house cleaning, landscaping, etc.? When was it formed/incorporated? What is its legal entity? Are you home-based, virtual, separate brick and mortar business?
How many people are ready to work with you on this co-op idea? Or if your business already exists, how many full-time and part-time employees do you have? *
Required
What stage is your co-op in?
Clear selection
Do you have any of the following completed? (Check all that apply.) *
Required
What type of services are you seeking from SEC4CD? *
Required
Does your co-op or organization have a budget for technical assistance? *
Do you  need interpretation (spoken) or translation (of written materials)? If so, which languages? *
Our "Office Hours" will be held virtually through Zoom. Do you have access to a computer and internet? *
How did you find out about us? *
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Southeast Center for Cooperative Development. Report Abuse
Google Forms