Counseling Intake Form

First Name *

Middle Name *

Last Name *

Email *

Phone *

Address *

I confirm that I want to receive content from this company using any contact information I provide.

Contact Type (Specific) *

Language Preference *

English

Spanish

Race *

Ethnicity *

Sex *

Sexual Orientation *

Do you consider yourself a person with a disability? *

Yes

Prefer Not to Say

Military Status *

Branch of Service (If applicable)

Referred by? (mark all that apply) *

Business Industry *

Stage of Business *

Exploring

Startup

Existing

In Business? *

Yes

If yes, Name of Business

Are You currently Exporting?

Yes

Business Address

What percentage of your business is women owned?

Conducting Business Online?

Yes

Are you 8a certified? *

Yes

Number of Employees

How Many of those employees are engaged in exporting aspect of your business?

For your most recent full business year what were your

Gross Revenue/Sales $ (recent full business year)

+Profits/ -Losses

Amount of gross revenues/sales related to exporting

Date Business Started (MM/YYYY)

1099 Contractors:

Nature of Counseling: *

Type of Meeting? *

Face to Face

Online (Virtual)

Telephone

CEED Business Center Intake Form

Last Years Household Income *

Number of people in your household? *

Will you be applying for a small business loan? *

Yes

What is your Credit Score? *

Are you involved in any lawsuit at this time or have you ever filed for personal or business bankruptcy protection? *

Yes

If Yes, furnish details here-lawsuit-business-bankruptcy

Which of the natural disasters affected your business? (if neither, don't select anything)

Covid-19

Hurricane

What is the estimated cost to start your business? (if not known, please give an approximate amount) *

Who is your target market? *

Which type of business industry are you interested in? *

Which of the following loans have you applied and received money from?

What is the total amount of funding you received in any of the above loans? (if none, enter 0) *

For Food Based Businesses: Do you have a certified kitchen?

Yes

For Food Based Businesses: Do you have a commissary?

Yes

Duns#

NAICS

Which certifications do you possess? (if neither, don't select anything)

How did you hear about CEED? *

Who is your City Council Member? (if unknown, type unknown) *

Who is your County Commissioner? (if unknown, type unknown) *

Who prepares your Payroll? (if not applicable, type "N/A") *

Are you interested in speaking with a Payroll/HR Specialist? *

Yes

Are you ready for tax season? *

Yes

Media Release Form

I grant permission to CEED to use my information, photographs and/or video for use in publications including videos, email blasts, recruiting brochures, newsletters, and magazines and to use my image in electronic versions of the same publications or on the CEED website or other electronic forms of media. I have read this release before signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms on this release.

Yes

Intake Form Completion

Signature *

Clear