Business Point of Contact (manager, etc) First Name Last Name Phone Number Email Preferred Communication Method(s) Phone Email Postal Mail SMS Fax Business Owner First Name Last Name Phone Number Email Street Address City Postal Code State/Province Preferred Communication Method(s) Phone Email Postal Mail SMS Fax What resources do you go to for business advice? Newspaper TV Word of mouth Radio Internet Other Annual Household Income - None -Less than $67,000$67,000-$76,000$76,000-$86,000$86,000-$96,000$96,000-$103,000$103,000-$111,000$111,000-$119,000$119,000-$126,000More than $126,000 Number of Children in household Number of adults in household Ethnicity Select all that apply Asian Americans Black and African Americans Hispanic or Latino Middle Easterners and North Africans Native Americans and Alaska Natives Native Hawaiians and other Pacific Islanders Opted out of answering this Two or more races White Other Veteran Yes No Member of reserve or National Guard? Yes No Gender - None -FemaleMaleOtherTrans-Female Disability Yes No Birth Date MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year19251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025 Year Government Benefits received Aid to Families with Dependent Children (AFDC) Public Assistance Business Business Name Website Street Address City Postal Code State/Province Phone Number Date Business Started MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year19751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027202820292030203120322033203420352036203720382039204020412042204320442045204620472048204920502051205220532054205520562057205820592060206120622063206420652066206720682069207020712072207320742075 Year Type of Business Restaurant Retail Manufacturing Transportation Service Construction Other Legal Structure LLC C Corp S Corp Non-Profit Partnership Sole Proprietorship Not decided yet Have you obtained a business license? Yes No Which Merchant's Association/BIDs are you a part of? Washington Ave Prospect Heights Association (WAPHA) Parkside Empire Flatbush Ave Association (Parkside Empire) FAB Alliance BID Bed-Stuy Gateway BID Other Do you rent or own or sublet your space? Rent Own Sublet Hours of Operation Number of full time employees Number of part time employees Annual Revenue - None -$0-$50,000$50,000-$100,000$100,000-$250,000$250,000-$500,000$500,000-$750,000$750,000-$1,000,000$1,000,000+ Please describe your business needs currently What are your business goals over this year? Any success stories you would like to share? Which of the following loans have you received? - None -Small Business Legal Relief Alliance (SBLRA)SBA Loan (PPP, EIDL, CRP)Other Support from IMPACCT Legal assistance (e.g. SBLRA support) 1 on 1 counseling Workshops Other Small Business Project ReStart Assistance Submit
