First name
Required
Last name
Required
Middle initial
Suffix
Street Address
Required
City
Required
State
Required
Zip
Required
Primary phone number
Required
Secondary/alternate phone number
Email
Required
Country of Origin
Country of Origin
If 'Yes', please explain.
If you live outside city limits, please tell us where.
How many adults live in your household? (age 18+)
How many children live in your household? (below age 18)
If 'Yes,' when and where?
Please tell us about your most recent or current employer, including company, location, job title, start date, end date (if applicable), and most recent salary/hourly pay.
Will you need accommodations per the Americans with Disabilities Act? If so, please explain the assistance required.
Do you have a criminal record that has prevented you from receiving any resources that you need? If 'Yes,' please explain.
Will you need childcare support or assistance to participate in Empower?
Required
Yes No
If yes, how many children?
If you have a business, what is the name? If you do not have a business name yet, please give us a three- to four-word description to indicate what your business will do.
Business phone number (if applicable)
Business email address (if applicable)
Business website (if applicable)
Describe your business or business idea in 100 words or less. Include what products or services are, or will be offered, and who your primary customers are, or will be.
In 100 words or less, tell us how your business provides, or will provide, benefits to the people who live and work in the surrounding neighborhoods.
Briefly explain how, and/or why you came up with this business idea.
If 'Yes,' what was your total earned revenue in the last 12 months?
What is your business zip code, or where do you intend to be located if you do not yet have a location?
Not counting yourself or any other business partners, how many paid employees do you have?
How many are full time and the salary/hourly wages?
How many are part time and salary/hourly wages?
If 'Yes,' please briefly describe previous ventures.
If 'Yes,' please explain.
Why do you think people will use and/or purchase your products or services?
List up to three other businesses currently offering similar products or services that you see as potential competitors (local, regional, and national).
Taking into account all of your personal and professional responsibilities, how many hours a week are you willing to devote to your business development?
Taking into account all of their personal and professional responsibilities, how many hours a week are any partners you have willing to devote to your business development?
What other potential benefits are you hoping to gain not listed above?