Community Development Corporation of South Berkshire · Small Business Technical Assistance Intake Form

Owner Information

Demographic Information: we are required to collect the following information for purposes of anonymous data reporting. This information will not be used for a discriminatory purposes. If you have questions or would like to change this information in the future please contact Giulia at Giulia@cdcsb.org.

Name

*

First Name

Last Name

Email

*

Verify Email

*

Phone

*

Mailing Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Town of Residence

If different from mailing address.

Best way to contact you?

Email

Phone

Other

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

No

Prefer not to share

Do you identify as an immigrant?

*

Yes

No

Prefer not to share

Are you a veteran?

*

Yes

No

Prefer not to share

Are you a student?

*

Yes

No

Prefer not to share

Are you retired?

*

Yes

No

Prefer not to share

Are you a single parent?

*

Yes

No

Prefer not to share

What gender do you identify with?

*

Female

Male

Other

Prefer not to share

Do you identify as LGBTQIA+?

*

Yes

No

Prefer not to share

Do you identify as a minority?

*

Yes

No

Prefer not to share

What is your age?

*

Under 25

26-39

40-60

61+

Household Size and Income:

*

Please select the option that best describes your household size and gross annual income amount. Your gross annual income is required data needed to fund our CDCSB Small Business Program. Your data is only shared for reporting purposes and we prioritize our clients’ confidentiality.

Business Information

Business Name

*

Business Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

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 open?

*

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

What best describes your business status now?

*

Prospective business owner (more than 1 year from startup)

Pre-startup (within 1 year of startup)

Startup (business opened-sales/revenue for 3 months)

Stabilized (business operating/generating revenue)

Expanding (profitable/employing at least 1FTE)

What business setup do you have?

*

Check all that apply:

Business has a brick-and-mortar location

Internet-based business

Home-based business

Business has another arrangement (Please see below)

Please briefly describe your business arrangement if you selected that option in the previous question.

Please briefly explain the assistance you are seeking.

*

If you selected more than one category above please prioritize what type of help would be most beneficial.

Are you working with any other small business consultants? If so, who?

*

How did your business evolve from a concept to where it is today?

*

What currently feels easy about your business?

*

What currently feels hard about your business?

*

Where do you want to be in 3 to 5 years?

*

How much time do you have to work on your business each week?

*

How did you hear about the Small Business Technical Assistance Program at the CDCSB?

*

Agreement

*

I understand that the information given in this application will be used to determine eligibility for services provided by the Community Development Corporation of 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 of the business or prospective business receiving technical assistance. My agreement affirms that I will not hold the Community Development Corporation of 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 72 hours notice.

I agree.

I do not agree.