Identifying Information

Name:  Male Female

Address:

Phone:
Email:
Website:

How did you become aware of the West Texas Innovation Network?
 via an advertisement an agency referral word-of-mouth Internet search Other

Employment

Are you now:
 self-employed employed by someone else unemployed working full-time looking for work (even if employed) working part-time

Do you own a small business?  Yes No
If yes:
(a) how many individuals do you employ? ---12345678910111213141516+
(b) what type of business/industry?

Have you ever owned a business?  Yes No
If yes:
(a) approximate period of time in business
(b) what type of business/industry?

Are you planning to start a new business?  Yes No
If yes,
will it be a  private for profit business non-profit?
Describe your business idea:

Services and Training

Have you attended workshops or previously received assistance to start a small business?
 Yes No

Are you interested in attending workshops, or receiving business counseling?
 Yes No

Would you be interested in participating in a mentoring meeting?
 Yes No

Are you now or have you recently received any service or assistance from the Workforce Center?
 Yes No

Have you ever received counseling or met with the Small Business Development Center?
 Yes No

Have you previously participated in the ACU Springboard Ideas Challenge?
 Yes No

Please list any areas of special interest to you:

Optional Information

The West Texas Innovation Network is committed to working with all entrepreneurs and would appreciate your assistance in determining if our marketing efforts are effective. Please check all boxes, as applicable.

 Veteran Individual with a disability Ex-offender Public assistance recipients UI Claimant Military spouse Caucasian Black Hispanic Native American Asian or Pacific Islander

I certify that the statements and information contained herein are true, complete and correct to the best of my knowledge. Yes No