SBTA Assessment of Needs

Please fill out this assessment of needs completely and accurately as the grant funding needed to provide support depends, in part, upon collecting this information. Filling out this assessment of needs does not garantee admission to this program.

If you have any questions please email Giulia at giulia@cdcsb.org.

Disclosures: CDCSB 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, and your name or street address will not be reported. Income, city, state, zip code, family size, and other demographic data will be reported.

Business Name

Owner/Manager Name

First Name

Last Name

Contact Email

Verify Email

Phone

Mailing Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Town of Residence (if different from mailing address)

Business Information

Total Number of Employees (including owner)

Number of Full Time Employees

Number of Part Time Employees

What type of business do you own or plan to launch?

For example: restaurant, pet groomer, acupuncture, etc.

Is there another person who own this business beside yourself? If yes, please list the name(s).

What business setup do you have?

Check all that apply:

Business has a bricks-and-mortar location

Internet-based business

Home-based business

Business has another arrangement (Please see below)

Please briefly describe it:

Please list three things that are currently positive in your business:

Please list three obstacles you are trying to overcome:

What would you like your business to be like ideally five years from now?

How many hours per week would you be able to meet with a consultant and work on your business?

(You will need to set some time aside during the week to work with your consultant and/or work on the homework that was assigned to you)

Are you working/have you worked with any other small business consultants or organizations?

Yes

If you answered "yes" to the question above, please list all the organizations and/or consultants you have worked with.

If you chose "other", please explain:

Demographic Information

What gender do you identify with?

Female

Male

Other

Prefer not to share

Do you identify as a member of the LGBTQIA+ community?

Yes

Prefer not to share

Age:

Under 25

26-39

40-60

61+

Race: Please check one or more that apply to you.

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Hispanic or Latino

Other

Prefer not to answer

Do you identify as disabled?

Yes

Prefer not to share

Do you identify as an immigrant and/or non-native English speaker?

(check all that apply)

Yes, an immigrant.

Yes, a non-native English speaker.

No.

Prefer not to share.

Are you a veteran?

Yes

Prefer not to share

Are you a student?

Yes

Prefer not to share

Are you retired?

Yes

Prefer not to share

Are you a single parent?

Yes

Prefer not to share

Do you have any dependents?

What is your current employment status?

Check all that apply.

Starting a business as a result of unemployment

Working full time

Working part time

In school or training program

Homemaker

Laid off

Self-employed

Seeking employment

Working more than one job

Please add any additional information that you find relevant to the program.

Agreement

I understand that the information given in this application will be used to determine eligibility for services provided by the Community Development Corporation South Berkshire Small Business Technical Assistance Program and will be treated as confidential. The information provided in this application has been given freely and is true to the best of my knowledge. I affirm that I am the owner or manager of the business or prospective business receiving technical assistance. My agreement affirms that I will not hold the Community Development Corporation South Berkshire, or its representatives, liable for business outcomes based on counseling, training, or teaching I receive. I understand that if accepted into the program I will make any scheduling changes with at least 24 hours notice. I give my permission to the CDCSB to use my name, the name of my business/organization, and/or my picture or a picture of my business or organization for the purpose of promoting their programs, reporting on their programs, or securing additional funds for their program.

I agree.

I do not agree.

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.

First Name

Last Name

Date

(mm/dd/yyyy)