About You



Fields marked with * are required.

* First Name:
* Last Name:
* Home Street Address: Apt. Number:
* City:
* State: * Zip:
* Borough/County:
* Primary Phone:   -   -
Cell Phone:   -   -
Work Phone:   -   -
* Personal Email:

Age

  20-34   35-44   45-54   55+

Education: Check the highest level Attained

Some High School  
H. S. Diploma  
Some College  
College Degree  
Technical or Professional School:   Specify e.g. Beauty School, Massage Therapy
Advanced Degree:   Specify e.g.: MBA, Nurse Practitioner
Law  
Masters (MBA,MPA,MA,MS)  
PhD  

Languages Spoken Fluently:

If "other", please specify:

Country of Birth

  (you do not have to be a citizen)
If country not in list, please specify:

* How Did You Learn about the Institute? Select all that apply

If other, please specify:

* Have You Started a Business?

Yes No

* Is your business Check all that apply

Minority-owned, and/or
Woman-owned
MWBE, MWOB, certified, etc

* What Business Do You Own or Want to Start? Select All That Apply or Write In at Other

Social Services/Academic     
     elderly care     
     child care     
     non profit     
     social work     
     teacher     
Beauty/Alternate Life Style     
     spa services     
     image, speech consulting     
     alternate health aids: exercise; vitamins     
Professional Services/Consulting     
     accounting     
     legal/law     
     bill paying     
     public relations/advertising     
     typing; customer service     
     answering and office services     
     architect     
     career counseling     
     speech; tutoring; linguist     
     recruiting     
Domestic Services     
     ironing/laundry; home cleaning     
     dry cleaning     
Creative Services     
     photographer; video     
     children’s activities     
     arts and crafts; pottery; painting; jewelry     
     writer; publishing     
     interior designer     
     graphic design; promotional     
     event planning     
     theater     
Pets     
     veterinarian     
     grooming; boarding; sitting     
Fashion     
     retail     
     design; manufacturing     
Real Estate     
     sales     
     development; construction     
Retail Store     
     eyeglasses     
     jewelry     
     other      Specify
Medical     
     physical therapy; physician; nurse; nurse practicioner; PA     
     dental     
Internet/Online/Website     
     marketing; sales     
     design; programming; development     
Food     
     restaurant     
     catering     
     Other      Specify
Other Please specify the type of business     

Business Status:

* Are you employed now?
Yes
No
I work in my business
 Current Position: describe

Approximate annual net Income:

Income source: select one
business
job
combination of business and job
other
Approximate annual net Income amount: select one
Under $20,000
$20,000-50,000
$50,000-$100,000
$100,000+

* What Services Can Assist You? Check all that apply

I want to know if I have what it takes to run a business
I need help deciding what kind of business to start
Do I have a viable business idea
I need help with learning the basics of starting a business
I need help with writing a business plan
I need financing
I need a mentor or advisor who knows my business      name the specialty
I need marketing and promotion advice
I need Web design or Internet/computer related help

*Why Do You Want To Start a Business?

Financial independence  
Extra income  
Work for myself vs. someone else; freedom; less stress  
More control over future  
Creativity fulfillment; challenge  
Build for children's career  
Work from home  
Flexible hours  
Health issues  
Help others  

To ensure that our services are more effective and responsive to the community, the Institute requests the above information. The data is kept strictly confidential and is not shared with any other institutions or mailing lists. There is no fee to participate in our seminars.