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MBAC - Intake/Request for Counseling Form
MBAC Intake Form
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了解详情
* 表示必填
电子邮件地址
*
您的电子邮件
Owner First Name
*
您的回答
Owner Last Name
*
您的回答
Co- Owner Name (first and last if applicable)
*
您的回答
Company/Business Name
*
您的回答
Are you currently in business?
*
Yes
No
Date business was established
*
年
/
月
/
日
Business/Organization Status
*
0
1 to 3 years
4 to 5 years
6+ years
Business/Organization Health
*
Exploring Business
In Business _ Failing
In Business - Healthy
In Business - Stagnant
In Business - Weak
其他:
Business/Organization Structure
*
C- Corporation
Foreign Corporation
Foreign Limited Liability Corporation
Foreign Limited Liability Partnership
Individual
Limited Liability Corporation (LLC)
Limited Partnership
Non-Profit
Partnership - Limited Liability
S -Corporation (Sub-Chapter)
Sole Partnership
Business Industry (i.e. Construction, Health Care, Transportation)
*
您的回答
Provide FULL list of products or services you offer. (This information will help us connect you to opportunities/contacts in your scope of service)
*
您的回答
Business Address
*
您的回答
City
*
您的回答
State
*
您的回答
Zip Code
*
您的回答
County
*
您的回答
Contact Number (Home/Cell/Business)
*
您的回答
Business Email Address
*
您的回答
URL/Web Address
您的回答
Average Number of Employee(s)
*
您的回答
Average Yearly Gross Sales
*
您的回答
Owner(s) yeas of experience in field
*
您的回答
Does/Doing Business with a Government Agency
Yes
No
清除所选内容
DUNS# (if applicable)
您的回答
UEI# (if applicable)
您的回答
NACIS# (if applicable please provide)
您的回答
FEIN# (if applicable please provide)
您的回答
PLEASE COMPLETE DEMOGRAPHIC INFORMATION BELOW SO WE CAN CONTINUE TO GET FUNDING TO PROVIDE FREE SERVICES TO BUSINESSESS
DEMOGRAPHIC INFORMATION
Gender
*
Male
Female
Prefer not to say
Ethnicity
*
Black/African American
Hispanic/Latinx
Native American/Indian
Pacific Islander/Native Hawaiian
Asian
White
Other
Military Status
*
Active
Retired
Reserves
None
Age
*
18 to 24
25 to 34
35 to 44
45 to 55
55 to 64
65 to 74
75 and over
Highest Education Achieved
*
High School/GED
Some College
Associates (2yr Degree)
Bachelors (4yr Degree)
Post Graduate
Doctorate
Did not complete school
Income Level
*
Less than $4,999
$5,000 to $9,999
$10,000 to $14,999
$15,000 to $24,999
$25,000 to $34,999
$35,000 to $49,000
$50,000 to $74,999
$75,000 to $99,999
$100,00 plus
How did you learn of MBAC's counseling services
*
Newspaper
Radio
Bank
City of Akron
State of Ohio
Word of Mouth
Email
Chamber of Commerce
Other
Referral Center
*
Summit
Stark
Richland
Wayne
Other
Are there any additional services you would like to receive from: MBAC and/or The Akron Urban League?
*
您的回答
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