Spanish Name of the Form Name* First Last Phone*Company Name Your Current Employment Status*Self Employed Full TimeSelf Employed Part TimeEmployed Full TimeEmployed Part TimeDisplace HomemakerUnemployedPublic AssistanceRetiredWhat is the current status of your business?*No longer interested in starting a businessIn Process of Starting or Acquiring a BusinessDecline in existing businessNo change in existing businessRetained/Saved businessStarted a business: PLEASE INCLUDE START DATE IN BOX BELOWIF Started a business, date business was formed* Income Generated by the Business is:*Main Source of IncomeSupplementary IncomeNo Income From BusinessThe Number of Full-Time Employees on Staff. DO NOT INCLUDE OWNER. If none put "0"*The Number of Part-Time Employees on Staff. DO NOT INCLUDE OWNER. If none put "0"*The Business Facility is*Home BasedOwn Outside FacilityRent Outside FacilityWhat Was the Gross Income Generated by the Business in the last 12 months? If none put "0"*Did You Receive Funding from either: family, friend, investor, crowd funding, bank, credit union, etc since you first started working with WEDC or since you last completed a survey?*YesNoLoan Information*Date of LoanFinancial Institution/Funder NameLoan AmountPurpose/Use of Funding Was the funding an SBA loan?*YesNoDid you receive a government contract in the last 3 months?*YesNoContract Information*DateAgency or AuthorityAmount Your NYS Minority/Women Business Enterprise (MWBE) Certification Status. Overview of criteria http://esd.ny.gov/MWBE/Qualifications.htmlHave Not AppliedApplication SubmittedCertifiedCertification DeniedNot EligibleWhat subjects would you like to learn more about? Also please give us a brief update on your business. Have you pitched an idea to a potential client, developed a new product, received any awards, etc.?CommentsThis field is for validation purposes and should be left unchanged.