*Owner(s) Name(s)
Separated by comma

*Business Name

*Address/City/State/Zip

*County of Residence

*Email(s)
Separated by comma

Website(s)
Separated by comma

*Phone
Home, Work and/or Cell; Separated by comma

*Business Address/City/State/Zip

*County of Business

Business Phone
(if different)

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Business Structure

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*Business Plan Completed Started Idea outlined but not started Not sure yet of business idea

*What month & year did you open or do you anticipate opening your business?

*Is this business: 51% or more woman-owned 51% or more minority-owned Neither

*Business Form Sole Proprietor Partnership Corporation LLC - Limited Liability Company S - Corporation C - General Corporation Unsure

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Business Operations

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*Where will this business be operated? Home Leased Space Incubator Space Owned Commerical Space

*Business Type Service Agriculture Retail/Wholesale Manufacturing Transportation Other

If Other, please specify:

*Describe your product or service:

*Will your business export or import with other countries? Yes No

Check if interested in learning more

*Will this business have paid employees? Yes No

#Part-Time

#Full-Time

*What do you anticipate gross receipts of the business to be in the next 12 months?

*Current investment status of business Self-Funded Friends/Family Bank Investors Other

If Other, please specify:

*Primary desire for participating in ACEnet Business Cohort

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Business Technology

General Computer Skills:

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*Word Processor Have not used General knowledge Proficient

*Spreadsheet Have not used General knowledge Proficient

*Publishing/Design Software Have not used General knowledge Proficient

*Internet Browser Have not used General knowledge Proficient

*Accounting Software Have not used General knowledge Proficient

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Demographic Information

We receive part of our funding from government grants that require us to demonstrate the impact of our efforts on the economy. The following questions serve as a basis for this determination. In the future we will be contacting you about how well you and your business are doing. Our continued funding depends on our ability to collect this information. All information will be kept confidential. We do not report individual data to any government or private agency. All reports are aggregated and anonymous. Answering these questions is strictly voluntary and exclusion of these questions will not determine your eligibility for the class. Thank you for your cooperation.

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Ethnic Background African-American Asian/Pacific Islander Caucasian Native American Other

If Other, please specify:

Gender Male Female

Highest Education Level Some High School High School or GED Some College Associate Degree Bachelors Degree Graduate Degree Technical/Vocational School Certificate/Diploma

Veteran Yes No

Disabled Yes No From Military Service

Main Source of Household Income Self-Employment Working for Someone Else Public Assistance Other

If Other, please specify:

Individual Gross Income Last Year 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 or over

Household Gross Income Last Year 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 or over

How many people are in your household age 18 and above?
Including yourself

How many people are in your household under age 18?

*Required