Operating Business Registration

Personal Information

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

Demographic Information

Date Of Birth*
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 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

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.

If you have any questions, please call 818-894-8800 or email info@iconcdc.org. Thank you for your interest in our training and/or business counseling services.

*Learn more about the funding regulations for Business Source, including CFR 570.506(b)(5) and (6). (Link)

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