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Chamber’s Intake Questionnaire
(Please fill out form legibly and complete all fields)
Date *
Business Name *
Type Of Business *
Gross Revenue *
Contact Name *
Email Address *
Firm Address
Phone *
Race
American Indian/Native American
Asian/Pacific Islander
Black/African American
Caucasian
Hispanic
Disabled
Yes
No
Other (please specify):
Website:
Active Duty
Yes
No
Service Disabled
Yes
No
Veteran
Yes
No
Spouse
Yes
No
Tax ID: *
State Of Incorporation: *
Date Started:
Are there affiliated entities:
# of Employees:
Language used to conduct business
Legal Entity
C-Corp
S-Corp
Proprietorship
LLC
Partnership
Not Defined
Are you currently in Business?:
Yes
No
Are you a homeowner?
Yes
No
Certifications:
ByBlack
8(a)
Hubzone
SDVOSB
Woman Owned
Other
Name of your financial institution: *
List All Owners, Officers, and % Ownership:
What are the areas in your business where you would like assistance (i.e., business plan, webpage development, accounting services, etc)
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