Renaissance Client Intake Form

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We thank you for applying for Renaissance's services and for sharing information about you and your business/business idea. Our goal is to help Bay Area entrepreneurs reach their financial and business goals. The information you provide gives us the information needed to:

1. Assess your entrepreneurial needs and support your progress.
2. Receive the financial support we need to provide free or affordable services to aspiring and established entrepreneurs like you.

All information will be kept confidential. We will not share this information with any other person, agency, or entity outside of Renaissance without your permission.

If you have any questions, please let us know. Thank you!

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E-Mail-Adresse *

What device are you using to access our online courses? *

Laptop

Smartphone

Have you ever completed an online class? *

Yes

Have you ever used Zoom for online training? *

Yes

Have you ever used Google Classroom for online training?

Yes

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First Name *

Last Name *

Address *

City *

State *

Zip Code *

Home Phone

Cell Phone *

1. How did you hear about Renaissance? *

Provide name of specific media (website, social media,) agency, person ororganization:

2. Did you consider options outside Renaissance when looking for business development services? *

Yes

Pflichtfrage

If “Yes”, why did you choose Renaissance instead of other organizations?

3. Gender *

Female

Male

Transgender

Gender Queer

4. Sexual orientation (optional):

LGBTQ

Heterossexual

Sonstiges:

Auswahl löschen

5. What is your date of birth? *

(month/day/year)

JJJJ

6, Are you Hispanic or Latina/o? *

Yes

7. Race: *

(check all that apply)

Native American or Alaskan Native

Native Hawaiian or other Pacific Islander

White/Caucasian

Black or African American

Asian

Sonstiges:

Pflichtfrage

8. Do you consider yourself an immigrant to the US? *

Yes

9. Do you have a disability? *

Yes

10. Veteran Status: *

Not Veteran

Veteran

Service Disabled Veteran

11. Military Status: *

Non Military

Member of Reserve or National Guard

Currently on Active Duty

12. What is your highest level of education? *

Less than 12 years of education

High School Graduate

Some college, Associate degree or Industry Specific License

Bachelor’s Degree (BA, BS, etc.)

Masters/Graduate degree (MA, MS, MFA, MBA, etc.)

Doctorate/Postgraduate (PhD, MD)

13. What is your employment status? (check all that apply): *

Self-employed Full-time

Self-employed Part-time

Self-employed Seasonal

Employed Full-time

Employed Part-time

Employed Seasonal

Contract/consultant

Day laborer

Unemployed

Retired

14. Are you a single parent? *

Yes

15. Are you the head of household or main wage earner? *

Yes

16. Household Size: including yourself, your spouse/partner, and dependents *

How many people are in your household sharing income & expenses?

16.1 Number of children under 18 living in your household? *

17. Household Income: estimate your most recent annual household income from ALL sources and before taxes: *

$ _____for _____(yyyy) This information will be kept CONFIDENTIAL

18. Does anyone in your household (including you) receive public assistance (housing, food, disability, etc.)? *

This information will be kept CONFIDENTIAL

Yes

What is your income source? *

This information will be kept CONFIDENTIAL

Tax Return

CalWorks

Food stamps

Medi-cal

Unemployment

Supplemental Security Income (SSI)

Payroll Stub

TANF

Social Security Disability Income (SSDI)

VA Service-Connected Disability Compensation

VA Non-Service Connected Disability Pension

Retirement Income from Social Security

Pension

Child Support

EITC

Sonstiges:

Job Category *

Officials and Managers (Includes: officials, executives, middle management, plant managers, department, managers and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, and kindred workers)

Professional (accountants and auditors, architects, artists, chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, personnel and labor relations specialists, physical scientists, professional nurses, personnel and labor relations specialists, physical scientists)

Technicians (Includes: computer programmers and operators, drafters, engineering aides, junior engineers, mathematical aides, licensed, practical or vocational nurses, photographers, radio operators, scientific assistants, technical illustrators, technicians (medical, dental, electronic, physical science), and kindred workers.

Sales: (Includes: advertising agents and sales workers, insurance agents and brokers, real estate agents and brokers, stock and bond sales workers, demonstrators, sales workers, and sales clerks, grocery clerks and cashier-checkers, and kindred workers.)

Office and Clerical (Includes: bookkeepers, collectors (bills and accounts), messengers and office helpers, office machine operators (including computer), shipping and receiving clerks, stenographers, typists and secretaries, telegraph and telephone operators, legal assistants, and kindred workers.)

Craft Workers (Includes: the building trades, hourly paid supervisors and lead operators who are not members of management, mechanics and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers, painters (construction and maintenance), motion picture projectionists, pattern and model makers, stationary engineers, tailors, arts occupations, hand painters, coaters, decorating occupations, and kindred workers.)

Operative: (Includes: apprentices (auto mechanics, plumbers, bricklayers, carpenters, electricians, machinists, mechanics, building trades, metalworking trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, dressmakers and sewers (except factory), dryers, furnace workers, heaters, laundry and dry cleaning operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (except construction and maintenance), photographic process workers, stationary firefighters, truck and tractor drivers, knitting and weaving machine operators, welders and flamecutters, electrical and electronic equipment assemblers, butchers and meat cutters, inspectors, testers and graders, handpackers and packagers, and kindred workers.

Laborer: (Includes: garage laborers, car washers and greasers, groundskeepers and gardeners, farmworkers, stevedores, wood choppers, laborers performing lifting, digging, mixing, loading and pulling operations, and kindred workers.

Service Worker: (Includes: attendants (hospital and other institutions, professional and personal service, including nurses’ aides and orderlies), barbers, charworkers and cleaners, cooks (except household), counter and fountain workers, elevator operators, firefighters and fire protection workers, guards, doorkeepers, stewards, janitors, police officers and detectives, porters, servers, amusement and recreation facilities attendants, guides, ushers, public transportation attendants, and kindred workers.

Pflichtfrage

19. What is your business status? *

I do not intend to start or own a business. I am here for professional or personal development.

I currently do not have a business. I have ideas and want to start one.

I currently do not have a business. I have taken concrete steps and am committed to starting one.

I already own a business and want to grow it.

I already own a business and I’m here to start another business.

20. What business challenges are you currently facing? *

Financial challenges (i.e. lack of capital, access to financing...)

Financial management (bookkeeping, cash flow, projections...)

Work-life balance/time management

Motivation and discipline

Mentorship, coaching and guidance

Legalities, permits, licenses, etc.

Marketing and sales

Hiring and managing people

Self-confidence

Sonstiges:

21. Business Name:

Enter your company name (if you already have one).

22. Describe your business or business idea: *

please be specific and include industry: e.g. restaurant, retail, etc.

23. Is your business making regular sales of your product or service?

Yes

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24. When did your business start having regular sales (official business start date) or when do you intend to makeregular sales?

JJJJ

25. Business Address:

(Address, City, State, Zip Code)

25.1 Website:

25.2 Business Email:

25.3 Business Phone:

25.4 Social Media handles:

Facebook, Instagram, LinkedIn, TikTok, or other

26. What were your business sales/revenues last calendar year?

(estimates are OK)

27. Do you pay yourself a salary or pay bills or personal expenses from the business?

Yes

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27.1 If “Yes”, how much did the business pay you last calendar year? (estimates are OK)

28. What is your business ownership structure (legal entity)? *

Sole proprietorship

Cooperative

S Corporation

B Corporation

LLC

Not yet established

Partnership

C Corporation

Sonstiges:

What percent of your business is owned by - Women:__________% Men:____________%

31. Do you have a DUNS number? *

A nine-digit number that identifies companies worldwide, called the Universal Data Numbering System. DUNS is a system recognized worldwide that was developed by Dun & Bradstreet (D&B) and that assigns a unique identification number to companies.

Yes

31.1 If “Yes”, please provide:

32. Do you have a business license? *

Yes

32.1 If “Yes”, issuing City/County:

33. How much do you work for this business? *

Full time (>35 hours/week)

Part time

Seasonal/temporary

I haven't started my business yet

34. Does your business support any jobs (employees, contractors or business partners)? *

Yes

34.1 If “Yes”, provide the number of jobs that your business supports. Don’t include yourself. *

Today's date *

(Month, Day, Year)

JJJJ

Client Signature (print full name) *

Full name

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