Valley Community Development Small Business Intake Form Disclosures: Valley Community Development will follow strict rules to protect your confidentiality. The personal data collected below including name, street address, email address and any other personally identifiable information is protected by the Data Privacy Act. You will never be named in any reports. Your responses may be looked at individually by the funding source, or contractors hired by the funding source to collect and analyze data, your name or street address will not be reported. Income, city, state, zip code, family size, and other demographic data will be reported. Contractors of HUD/DHCD or any City/State agency are covered by the same Data Privacy Act requirements to protect your privacy and staff must demonstrate that they have systems in place to protect against data disclosure. Contact Information Legal First Name Legal Last Name Preferred Name PronounsHe/himShe/herThey/themJust my nameOther What pronouns do you use? Home Address Home City Home State Home Zip Code Email Phone Cell / Alternate Phone Business Information (If you do not have official business information, enter your personal information.) Business Name If you do not have a business name, please leave this field blank. Business Address Business City Business State Business Zip Code Business Email Business Phone Number Other Owners of the Business Is there another person who owns this business besides yourself?YesNo Name(s) of additional business owner(s): Email address(es) of additional business owner(s): What type of small business do you own? For example: restaurant, pet groomer, acupuncture What stage of Business are you in?Prospective Business Owner (about 1 year from starting a business)Pre-Startup (within one year of startup)Startup (business operating/generating revenue less than 1 year)Established Business Clients (in business more than 1 year and generating income) Do you have any employees? YesNoIf you are paying yourself, please count yourself as an employee. How many employees do you have? How many of your employees are full-time workers? How many of your employees are part-time workers? What business setup do you have?Please select... Business has brick-and-mortar location Home-based business Business has another arrangement Are you working with any other small business consultants? If so, who? What are the top 3 business goals that our Valley Community Development Small Business Consultants could help you with? Demographic Information Combined Household gross annual income: Your gross annual income is required data needed to fund our Valley Community Development Small Business Program. Your data is only shared for reporting purposes and we prioritize our clients' confidentiality. Please enter a number only, with no characters. How many people live in your household? Do you identify as LGBTQ+?YesNoChose not to respond GenderMaleFemaleNonbinaryOtherChoose not to respond Are you disabled?YesNoChoose not to respond Are you a Veteran?YesNoChoose not to respond Valley asks the following two questions as a requirement from several funding sources that help make our programs free to the community. Do you consider yourself Hispanic or Latino?YesNoChose not to respond Select the following race you identify with: AsianBlack or African AmericanNative American or Alaskan NativeNative Hawaiian or Pacific IslanderWhiteMultiracialChose not to respondRacial categories defined by OMB & US Census. For us to address the needs of our community, it's important to us that we learn about the diversity of those we serve. Please select all that apply to you:ArabAfricanAfrican AmericanAsianBlackCaribbeanEast AsianLatino/Latina/LatineMiddle Eastern or North AfricanNative AmericanNative AlaskanNative HawaiianPacific IslanderSouth AsianWhiteOtherChose not to respond Other: Are you an immigrant?YesNoChoose not to respond What is your native language? Do you consider yourself a minority? YesNo By typing my name below, I certify that the information contained herein is true, complete, and correct to the best of my knowledge and belief. I affirm that I am associated with the business or prospective business receiving technical assistance. Ok Name: Date: Would you like to subscribe to our newsletter?YesNo How did you hear about us? WebsiteSocial mediaAnother organizationFamily/friendsFlyerNewsletterOther Other Small Business Client reCAPTCHA helps prevent automated form spam. The submit button will be disabled until you complete the CAPTCHA. Contact Information
