Crotty Center Client Engagement Form
From consultation projects to micro-loans, the Crotty Center offers a variety of resources and opportunities for entrepreneurs and small businesses to receive support through experiential learning activities. In order to be sure we are connecting you to the right resources, we have some questions that will help us better understand you, your business, and your business needs. Your answers will be used to connect you with available resources, so please be sure to answer the following questions as accurately as possible.
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Email *
Questions about You
1) Full Name
2) Email
3) Phone Number
4) How old are you?
Clear selection
5) What is your ethnicity
Clear selection
6) What is the highest level of education you have completed?
Clear selection
7) What gender do you identify with?
Clear selection
8) What is your home zip code?
9) Are you a veteran?
Clear selection
10) Do you identify as having a disability as defined under the Americans with Disabilities Act (https://adata.org/faq/what-definition-disability-under-ada)? [select all the apply]
Questions about your business or organization
11) What is the legal designation or name of the business or organization?
12) What is the best way to describe the businesses or organization?
Clear selection
13) Is your business or organization a tax designation 501(c)(3) or limited liability (LLC)?
Clear selection
14) How would you describe the business or organization in 1-2 sentences?
15) What industry best describes the business or organization?
Clear selection
16) Did you start this business or organization?
Clear selection
17) What is your position in the business or organization?
18) Is this the first venture you started?
Clear selection
19) What stage best describes the business or organization today?
Clear selection
20) What is the estimated annual revenue of your company or organization?
Clear selection
21) How long has the business or organization been in operation?
Clear selection
22) Including yourself, how many full-time (over 32 hours) workers are employed by you?
23) Including yourself, how many part-time (less than 32 hours) workers are employed by your business?
24) Have you completed a business plan or lean canvas model for the venture?
Clear selection
25) What is the website for the business? (if applicable)
26) What is the physical address for the business or organization? (if applicable)
Venture Needs
27) What do you need help with to support your venture idea? (only for those who selected option "a" in #19)
Clear selection
28) What are the business or organization's needs? (select all that apply)
29) Would you like to share any additional information or comments?
30) How did you hear about the Crotty Center?
Clear selection
31) Who referred you to the Crotty Center or to complete this inquiry form?
Clear selection
32) To better support your venture, we partner with many different service providers that support entrepreneurs. If we believe that one of these organizations can support you would you allow us to share your information with them?
Clear selection
Thank you for your information. Someone will be in touch with you soon to follow up on your inquiry submission. If you have any questions, please contact Kat Cordier, the Associate Director of the Crotty Center, at kcordier1@udayton.edu.
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