SER Entrepreneurship Registration Form Enrollment ID Application Status Contact ID User Enrollment Owner Employment ID GenderPlease select... Female Male Non-binary Other Which location are you applying for?Please select... Albuquerque, NM Dallas-Fort Worth, TX Denver, CO Houston, TX Los Angeles, CA Long Beach, CA Milwaukee, WI Other Albuquerque, NM Dallas-Fort Worth, TX Denver, CO Houston, TX Long Beach, CA Other- CA Other Albuquerque, NM Dallas-Fort Worth, TX Denver, CO Houston, TX Los Angeles, CA Long Beach, CA Milwaukee, WI Other Albuquerque, NM Dallas-Fort Worth, TX Denver, CO Houston, TX Los Angeles, CA Long Beach, CA Milwaukee, WI Other First Name Last Name Birthdate AgePlease select... 18-24 years old 25-34 years old 35-55 years old 56-65 years old Over 65 years old Email Street Address City StatePlease select... AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip / Postal Code Primary Phone Enter phone number where you can be reached Secondary Phone Enter secondary phone number if available Demographic Information All demographic information collected will remain strictly confidential between you and your assigned onsite Program Facilitator to improve the business development services. Aggregated demographic data will be used for statistical purposes only and your answers will never be identified. This form is intended to assist your assigned onsite Program Facilitator to better prepare you to grow and sustain your small business and/or to become a successful entrepreneur. Are you a veteran or spouse of a veteran?YesNo RaceBlack/African AmericanAsianWhiteMulti RaceAmerican Indian or Alaskan NativeNative Hawaiian/Pacific IslanderHispanic or LatinoOther EthnicityNot Hispanic, Latino, or Spanish originMexican, Mexican American, ChicanoPuerto RicanCubanOther Hispanic, Latino or Spanish origin Other Origin What is your preferred language?EnglishSpanish Do you have a disability?YesNo Family StatusPlease check ALL that apply. This information is gathers to be inclusive of individuals of differing family status. Married Without ChildrenMarried With ChildrenSingle ParentSingle Without ChildrenLiving with RelativesLiving on My Own (not dependent on others) Work Experience Name at least your last three (3) job titles and years of experience in each. You may also include volunteer and military experience. Please use the "Add another work experience" button to add more. Type of ExperiencePlease select... Job Volunteer Military Position/Title Name of Employer/Organization Start Date: Date Hired Still Employed?YesNo End Date: Skip question if still employed Reason for Leaving Enter brief description of reason for leaving. Enter "N/A" if still employed. Duties Enter a brief description of your job duties. Hourly Wage $ Education and Entrepreneurship Experience Education StatusPlease select... No grade school 1 year of school 2 years of school 3 years of school 4 years of school 5 years of school 6 years of school 7 years of school 8 years of school 9 years of school 10 years of school 11 years of school Completed 12 years of school but no HS diploma HS diploma GED or certificate of equivalency for HS 1 year of college completed 2 years of college completed 3 years of college completed BA/BS or equivalent Education beyond a bachelor's degree Master's degree Doctoral degree Vocational/technical degree Associate's degree If you completed an Associates or Bachelors Degree, what was your course of study? Name of last school attended. If currently attending school, list the school you are currently attending: Do you hold any professional certifications or licenses?Please select... Yes No If you entered "yes" to the previous question (professional certifications/licenses), name the certification(s)/license(s) you hold. If no, enter "N/A" Are you eligible to work in the U.S.? YesNoEligibility to work in U.S. does not preclude your participation in the program as it does not apply to those launching a business. Do you have an EIN number? YesNoAlso known as a federal tax identification number, and is used to identify a business entity. Are you currently employed?YesNo Check if you have never been employed. Annual Income Do any of the following employment barriers apply to you? Please check ALL that apply. This information is gathered to be inclusive of individuals with barriers to employment.Deficient in Basic Literacy SkillsSchool DropoutLong-term UnemployedAn OffenderPregnant/Parenting YouthLack of Work SkillsHomeless, Runaway, or Foster ChildVeteranOlder WorkerNone Do you have any self-employment experience?YesNo If you entered "yes" to the previous question (self-employment experience), describe type of business and for how long. Are you currently a small business owner?Please select... Yes No Are you interested in starting a small business?Please select... Yes No If yes, what industry?Please select... Banking/Finance Construction/Manual Labor Food & Beverage/Restaurant Government/public services contracting Professional Services Medical Care/Health Services Retail/Sales Other Goal Timeframe Please select... 6 - 9 months 10 - 18 months 19 - 24 months 25 - 36 months 37+ monthsWhat is your anticipatory goal timeframe? Small Business Development Business name Business Phone Business Email Business Address- Street Business Address- City Business Address- StatePlease select... AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Business Address- Zip / Postal Code How many years of experience do you have working in your industry?Less than 12 months12 months - 3 years3 - 5 years5 - 10 yearsMore than 10 years Is your business women owned or at least 51% owned and operated by one or more women?Yes No Business Information How long has your business been in operation?Pre-startup phase (not incorporated)1 - 18 months18 months - 3 years3 years or more Which of the options below best describes the industry or activities your business conducts? Select all applicable.Banking/FinanceConstruction/Manual LaborFood and Beverage/RestaurantGovernment/public services contractingProfessional ServicesMedical Care/Health ServicesRetail/SalesOther Other industry: Do you currently have a business plan?YesNo Do you currently have a business license?YesNo Do you have a DUNS Number?YesNo Does your business own or rent a space?YesNo Do you have a banking account?YesNo What source(s) of financing have you used or plan to use to finance your business?Bank loanLoan from family member/acquaintancePay-day loanPersonal savingsOther Other source of financing: Do you live in a Community Development Block Grant (CDBG) area?YesNo How many people does your business currently employ?Self-employed/ sole proprietor2 - 34 - 89 - 15Over 15 How many of your employees are full-time? If none, enter 0. How many of your employees are part-time? If none, enter 0. How many of your employees are seasonal/contractual? If none, enter 0. What was your business revenue for fiscal year 2020?$25,000 or less$25,001 - $50,000$50,001 - $150,000$150,001 - $400,000Over $400,000Unsure/prefer not to answer At the end of 2020, was your business operating at a profit, breaking-even, or operating at a loss?Operating at a profitBreaking-evenOperating at a lossUnsure/prefer not to answer Have you applied for a loan in the past 12 months or plan to apply for a loan in the next 12 months? Select what best describes your situation.Applied for a loan in the past 12 months and was approvedApplied for a loan in the past 12 months and was denied Will apply for a loan in the next 12 monthsNeither Other Loan application other: If you applied for a loan and was denied, why do you believe you were denied? If you have not applied for a loan, what best describes the reason(s) why you have not applied. Please select all applicable.Application process is too complicatedApplication process is too longBad credit scoreDon’t need a loanLoan amounts are too largeNot enough collateralOther Did not apply for a loan other: What are your biggest challenges to expanding your business?Assistance with a business plan, marketing or appropriate business software/ITAssistance with financial documents, budgeting, building credit, bank accountsAccess to capital such as matched savings programs, low-interest credit or business loansAccess to new markets/places to sell productsAssistance with development of new products or adoption of new technologiesAdult education opportunities/professional development opportunitiesOther Biggest challenge other: What other services would you be interested in learning more about?Assistance with a business plan, marketing or appropriate business software/ITAssistance with financial documents, budgeting, building credit, bank accountsAccess to capital such as matched savings programs, low-interest credit or business loansAccess to new markets/places to sell productsAssistance with development of new products or adoption of new technologiesAdult education opportunities/professional development opportunitiesOther Other services interested in: Are you a Street Vendor?YesNo Questions Specifically for Street Vendors Do you currently have a street vendor permit from the City and/or a health permit from the County?I currently have a peddler permit from the City.I currently have a health permit from the County.I have both permits.I have neither. If you do not have a permit, what best describes the reason(s) why do you not have one? Please select all applicable reasons.The application materials are not available in Spanish.The application process is too complicated.The application process takes too long.The permits cost too much.Other No permit other: If you do not have a permit, have you ever been fined for not having one or know someone who was fined? How much was the fine and who do you think reported you? If you sell food and beverages, where do you prepare your products?A commercial kitchenAt homeA restaurantOther Other food preparation location: If you do not prepare food in a commercial kitchen, what best describes the reason(s) why you do not use a commercial kitchen? Please select all applicable reasons.Commercial kitchens cost too much to useI don’t know what is a commercial kitchen or where to find oneThe application materials for commercial kitchens are not available in SpanishThe application process for commercial kitchens is too complicatedThe application process for commercial kitchens takes too longOther Other reason no professional kitchen use: How did you select the place where your business is located? Do you pay for the location?Yes, I payNo, I do not pay Location payment amount (monthly) Applicant Consent Consent to Release Media/PhotographI hereby consent to the use of media containing my likeness as captured during program activities, including photographs, videos, audio recordings and/or other media for the purpose of creating web, mobile, print and social media content to increase awareness, promotion and general public outreach of program activities. Checking below indicates I have read all the above and agree to its contents.Applicant agrees How did you hear about SER Entrepreneurship?Please select... In-person Referral Website Workshop Social Media Contact Information
