Business Name         <<< STEP 1 <<

First Name

Last Name
Email

(repeat)
Street Address

Street Address
City
State
Zip
Phone

1. What is your marital status?  Select Single Married Widowed Divorced Separated

2. What is your race?  Select African American Native American or Alaskan Native Asian White/Caucasian Native Hawaiian or Pacific Islander African American and White Asian and White Native American/Alaskan Native and White Native American/Alaskan Native and African American I do not wish to respond

3. What is your ethnicity?  Select Hispanic/Latino Non Hispanic

4. Are you Female or Male?  Select Male Female

5. What is your veteran status? Select Not a veteran Veteran Disabled Veteran Service connected disabled  

6. Do you consider yourself a person with a disability? No Yes

7. Are you the head of household? Yes No

8. What was the highest grade you completed in school?  Select 1 2 3 4 5 6 7 8 9 10 High School College 1 year College 2 years College 3 years or more College Graduate or higher

9. Have you taken any courses of training that are relevant to your business idea? No Yes

10. What is your current employment status?  Select Employed by someone else Employed by someone else & self employed Self employed Unemployed

11. How did you hear about our program?  Select Bank Newspaper Chamber of Commerce Internet Radio Television Magazine SBA Word of Mouth

12. Which of the following most closely resembles your current self employment situation? 
Select Thinking about starting a business Am in process of starting a business but have made no sales Have opened a business and made sales within the last 12 months Have been in business with sales for more than 12 months

13. How many adults are in your household?  Select 1 2 3 or more

14. How many children are in your household?  Select 0 1 2 3 4 5 6 7 or more

15. Did you receive any of the following assistance?

  W2 Unemployment SSI Rent Assistance Medicare Food Stamps SSDI Other

16. Is it important to you that this program targets women? Yes No

17. What was your gross (before taxes) household (not individual) income last year that supported all members of the household?

  Select Under $15,000 $15,000 - 24,999 $25,000 - 34,999 $35,000 - 44,999 $45,000 - 54,999 $55,000 - 64,999 $65,000 - 74,999 $75,000 - 84.999 $85,000 - 94,999 $95,000 - 99,999 $100,000 - 199,999 $200,000 - 299,999 $300,000 - 399,999 $400,000 - 499,999 $500,000 - & over

18. Is there someone else in your household earning income 

(for example spouse, partner, adult children, or relative)? Yes No

Already own a childcare business?   
Yes   No, take me to the end of this form.     << STEP 2 <<

Business Name

Mailing

Street Address

City
State
Zip

Business Phone

Business FAX

Business Email

1. What is the gender mix of the business owner(s)?  
Male (50%+) Female (50%+) Male/Female (50/50)

2. Is this a home based business?  Yes No

3. What is the race of the business owner? 
   Select African American Native American or Alaskan Native Asian White/Caucasian Native Hawaiian or Pacific Islander African American and White Asian and White Native American/Alaskan Native and White Native American/Alaskan Native and African American I do not wish to respond

4. Ethnicity of business owner? Select Hispanic/Latino Non Hispanic

5. Is the business certified as a DBE, MBE, WBE or woman owned business for preferential contracting purposes by any government agency?
  Yes No

6. What is the website address of your business? 
  

7 Is the location of the business Urban or Rural? Urban  Rural 

8. When did you start your business?

9. What is the type of your business entity? 
   Sole Proprietor  Partnership  Corporation S - Corporation Limited Liability Company

10. What is your business type? Select Retail Manufacturing Service Construction Wholesale Finance

11. Do you conduct business on line? Yes No

12. What was your business's total sales/gross receipts in your last taxable year?
     Select Under $15,000 $15,000 -$100,000 $100,000 - $500,000 $500,000 & Over

13. What was your business's net profit (OR net loss) BEFORE taxes (as reported on your tax return) in your last taxable year?
     Select Loss Under $15,000 $15,000 - $100,000 $100,000 - $500,000 $500,000 and Over

14. How many jobs has your business created in the last twelve months? (please fill in) Jobs created This question is asking you to calculate the total number of jobs as follows; each full time job equals one job; and, each part time jobs needs to be reported as its full time equivalent (i.e. three half time jobs: 3 x .5 = 1.5 full time jobs).

15. What is the number of jobs retained because of your business in the last twelve months?

16. As of today, is your business still in operation? Yes No

17. What is the largest number of Full time employees in your business in the last twelve months?

18. What is the largest number of Part time employees in your business in the last twelve months?

Answer the following questions if you are a child care provider:

19. How many children are you licensed or certified to serve?

20. Are you at full capacity? Yes No

Request for Assistance and Certification

I request business management counseling and/or training from The Wisconsin Women's Business Initiative Corporation (WWBIC) which is funded partly by the US Small Business Administration. I agree to cooperate should I be selected to participate in surveys designed to evaluate 58A funded services. I understand that any information received by WWBIC will be held in confidence to the extent permitted 6y law. I further understand that the counselor or trainer in this program has agreed 1) not to recommend goods or services in which he/she has an interest and 2) not to accept fees or commissions developing from this counseling relationship In consideration of SBA's funding of WWBIC and the assistance to be furnished, I agree to waive all claims arising cut of this assistance against SBA personnel, WWBIC, its host organization, and the resource counselors) who assisted me. I formally authorize WWBIC to use my name and image for promotional activities sponsored by WWBIC.

I certify that all my statements on this form are correct to the best of my knowledge and that I will cooperate in providing follow up information needed to evaluate the effectiveness of the program if asked by an authorized representative of WWBIC.

Name            << STEP 3 <<

Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2005 2006 2007 2008 Today's Date

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