EatsPlace Client Intake Form
By completing this form and/or participating in a tour, I understand am requesting assistance from EatsPlace.  I agree to provide all appropriate information requested in connection with this assistance. All information will be kept confidential. In consideration of EatsPlace furnishing the products and/or services, I waive all claims against EatsPlace that may arise from this assistance.  Thank you!
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Email *
Name (first name, last name) *
Is English your primary language? *
Do you identify as African-American, Latinx, and/or a woman (check all that apply)? *
Required
Date *
How did you hear about EatsPlace (check all that apply)? *
Required
Business / Organization Name *
Status
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Date Formed: (mm/dd/yyyy)
MM
/
DD
/
YYYY
 Filing State: (2 letter abbreviation)
Organized as:
Tax Status *
EIN:
NAICS Code:
DC Ward Number
Business/Organization Mailing Address: (if none, use personal address) *
Business Phone: *
Cell Phone: *
Website:
Social Media (Facebook / Instagram / Twitter)
Other: (Tiktok, LinkedIn, etc.)
Are you an owner of the business? *
List All Co-Owners/Partners: (Full names)
Do any of the Co-Owners/Partners identify as African American and/ or Lantinx? If so , which ones?
Do any of the Co-Owners/Partners identify as women? If so, which ones?
Are you LSDBE (Local, Small, and Disadvantaged Business Enterprise) certified?   *
Are you 8(a) or SBD certified by the US Small Business Administration? *
One sentence description of your concept: (How will you use EatsPlace or how can we help you?) *
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