EAC Intake EGL

Client Intake Form - Entrepreneur Growth Lab

As you may know, WEDC receives government funding for many of its programs. In order to demonstrate that we are reaching certain target markets, many of our funders require us to collect the following information to ensure that WEDC is serving the needs of diverse entrepreneurs. Our continued funding depends on our ability to collect this information. WEDC places great value on your personal privacy and the confidential facts and figures you disclose concerning your business activities. Information concerning you and your business is kept strictly confidential and is reported only in the aggregate unless prior approval is received from you. WEDC is able to offer its programs and services at affordable rates and/or reduced rates due to the support of Federal, State, Municipal, Corporate and individual contributors. In the future, we will be contacting you to update this information.

Business Information
Company Name
Tax ID Number
Stage of Business*
Form of Business*
Type of Business*
Usable Business Plan*
Client Information
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
County*
Telephone Number*
Cell Phone
Email*
Website
Gender*
- F (Female)
- M (Male)
- X (X-Gender)
Age*
Highest Education Attained*
Ethnicity/Race Group*
- Black/Non-Hispanic
- Black/Hispanic
- Hispanic (other than Black)
- Asian
- Native American
- Non-minority
- Other
Other Business Information
Date Business Started
MM slash DD slash YYYY
Business Facility*
Income Generated by Business is*
Gross Revenues/Sales $ for most recent FULL Business Year*
If no sales put $0.00
Number of Owners*
Number of Employees Full Time (DO NOT INCLUDE OWNER)
Number of Employees Part Time (DO NOT INCLUDE OWNER)
Percentage of Female Ownership*
Hidden
Gross Revenue/Sales $ for 2020*
If no sales put $0.00
Hidden
Gross Revenue/Sales $ for 2021*
If no sales put $0.00
Hidden
Gross Revenue/Sales $ for most recent FULL Business Year
If no sales put $0.00
MWBE Certification Status*
MWBE Applied Date
MM slash DD slash YYYY
MWBE Certified Date
MM slash DD slash YYYY
Designation Group/Status
Designated Group/Status*
- Veteran
- Dislocated Worker
- Disabled Individual
- MOB (Self Declared Minority Owned Business)
- WOB (Self-Declared Women Owned Business)
- MWOB (Self-Declared Minority & Woman Owned Business)
- Not a Minority Business
Employment Status*
How May We Help You*
PLEASE PICK 1 OPTION BELOW
- COVID Relief Funding/Grants
- Customer Service
- Product/Service Pricing
- Elevator Pitch/Intro Speech
- Business Training
- Business Plan
- Financing
- MWBE
- Budgeting
- Business Licenses
- Management
- Marketing
WEDC Office closest to your location*
Please select the WEDC office closest to your location.
Client Confirmation*
I have provided the information above, and understand that it will be kept confidential and used for loan assistance/business counseling by the Women's Enterprise Development Center. And program staff to verify compliance with project goals. And used for statistics purposes by Empire State Development Corporation.
I agree
Contract of Responsibility*
In order to establish a positive working relationship, both with the EAC Center and the program participants both parties should read, understand and agree to the following:

Women's Enterprise Development Center:
-Provide a comprehensive business training program for enrolled participant
-Provide support services that include one-on-one consultations, specialized additional training
where needed, information on available resources for loan/financing/funding opportunities
-Provide at least 10 hours of technical assistance training
-Assist participants in completing their business plans
-Work with participants on loans/financing and other funding applications

Participant agrees to :
-Attend all Sessions
-Arrive to all scheduled sessions on time
-If unable to attend a training sessions/appointment for assistance contact EAC Center
-If participating in a session, share information, resources and work to develop a positive working relationship with the group
-Complete all work assignments
-Complete a business plan
-Complete 10 hours of technical assistance
-Complete online survey on services provided
I agree
Consent*
New York State Department of Economic Development

I CONSENT to the use of my name and/or my likeness for the purpose of advertising or trade by
New York State Department of Economic Development (“DED”) or anyone authorized by that
Department to act on its behalf. “My likeness” includes a photograph, videotape recording, film or
artistic rendering of me, a recording of my voice, and/or reproductions of any of these. I agree that the
actual material involved, such as a photograph, negative, plate, videotape recording, film or audio
recording is and shall continue to be the property of the New York State Department of Economic
Development.

I GRANT PERMISSION TO New York State Department of Economic Development to use
my person, company name and information regarding the general nature of my business and the services
provided to me by a representative of the New York State Department of Economic Development.

I UNDERSTAND AND AGREE that I will not be compensated in any way for the use of my
name and/or likeness by the New York State Department of Economic Development. I also understand
that the New York State Department of Economic Development may incur expenses in connection with
the recording or reproduction of my name and/or likeness, and that I am free from any responsibility for
these expenses.

IF MORE THAN ONE (1) PERSON signs this consent, each person hereby agrees to the
preceding provisions.
I agree
Training Materials Confidentiality*
It is understood and agreed to that the below identified “Discloser “of Confidential Information may provide certain information that is and must be kept confidential. “Recipient” is willing to receive disclosure of the Confidential Information pursuant to the terms of this Agreement for the purpose of attending or teaching the Entrepreneurial Training Program. To ensure the protection of such information, and to preserve any confidentiality necessary it is agreed that:

1. The Confidential Information to be disclosed can be described as and includes: Internet access to all or part of the Women’s Enterprise Development Center’s core Entrepreneurial Training Program Curriculum which includes worksheets and power point presentations.
2. Recipient agrees that all Confidential Information shall remain the property of Discloser. Recipient agrees that this information is not to be duplicated, shared with any other party, or used in any other manner. Recipient agrees to take all steps reasonably necessary to protect the secrecy of the Confidential Information, and to prevent the Confidential Information from falling into the public domain or into the possession of unauthorized persons. Nothing contained herein shall be construed as granting or implying any transfer of rights to Recipient of the Confidential Information.
3. The Recipient agrees not to disclose the Confidential Information obtained from the Discloser to anyone unless required to do so by law.
4. This Agreement states the entire agreement between the parties concerning the disclosure of Confidential Information. Any addition or modification to this Agreement must be made in writing and signed by the parties.

WHEREFORE, the parties acknowledge that they have read and understand this Agreement and voluntarily accept the duties and obligations set forth herein.
I agree
Date*
MM slash DD slash YYYY

Client Intake Form - Entrepreneur Growth Lab

EAC Intake EGL

Business Information

Client Information

Other Business Information

Designation Group/Status

COMPANY

WEDC Westchester Women's Business Center

WEDC Mid-Hudson Women's Business Center