Business Startup Bootcamp Registration DRAFT

Personal Information

First Name* Last Name*
Address* City
Zip Code
Phone Number Email Address

Demographic Information

Date Of Birth* Gender*
Ethnic Group
Education Level*
Employment Status*
Family Size* Family Income*

Annual Income in 2016*

Business Information

Name of Business Type of business
Business Start Date Business Partner
Business Form
Please check ONE of the business registration documentation held by your business
Please provide notes to clarify the options selected above (i.e. date obtained, etc.)
Please also indicate any previous management/work experience.*
Business location*
If office/storefront, please type in your business address
Business Phone* Business Website
Are you operating this business full or part time?
How many employees are currently, or will be, working for your business?* (including yourself)
Are you seeking to hire additional employees? Are you planning a business closure?
Are you planning to lay off employees?
If yes to any or both of the previous two questions: How many employees are threatened by layoff/closure?
Please indicate your current monthly revenue (gross receipts)
Please indicate your annual Revenue (gross receipts) for 2015
Have you ever started/owned another business?
If yes, is it still operating?
Please describe the business and explain if it is no longer in business:
Are you in need of any of these assistance?*
List any other fields you might need assistance in

Business Startup Bootcamp Assesment Questions

Tell us about yourself* Educational Background/Work & Business-related Experience*:
The training requires basic computer skills to complete assignments. Please describe your computer skills*: Give a description of your business or business idea*:
How soon do you plan to launch or relaunch your business? Where do you see your business in 3 years?*
What are three outcomes you expect from this training? Have you participated in any other business training programs? If so, when and where?
Describe a challenging situation you have faced recently and how you overcame it?

Referral Information

How did you hear about this program? Please specify the answer of the previous question
(e.g. if you were referred by the Worksource please specify which one)

Terms and Conditions*

By clicking here, I certify that all my answers above are true and correct to the best of my knowledge. I also agree that by accepting to receive assistance from the BusinessSource Center I will cooperate and provide the BusinessSource staff with all requested information and documents to verify the outcomes reported in compliance with CFR 570.506(b)(5) and (6).

* is a required field.