Entrepreneur Training for Success Application, Fall 2010

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1. Contact Information. If one of these fields is not applicable (e.g., you do not have a website), please fill in "N/A".

Contact Information. If one of these fields is not applicable (e.g., you do not have a website), please fill in "N/A".   Name:
Country of Origin:
Address:
Address 2
City/Town:
State:	-- select state --AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming
ZIP:
Website address
Email Address:
Phone Number:

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2. Please provide the following information to help us characterize our client base.

	Age	Marital Status	Number of Children	Region of Origin	Annual Household Income	Highest Level of Education	Number of languages you speak	Length of time in U.S.	How long have you been part of EWI?
Select:	<1818-2425-3435-4445-5455-6465+ Please provide the following information to help us characterize our client base.   Select:   Age	SingleMarriedDivorcedWidowedCommitted Relationship Marital Status	012345+ Number of Children	North AmericaLatin/South AmericaWestern EuropeEastern EuropeMiddle EastAsiaAfricaOther Region of Origin	<$25,000$25,000-$49,999$50,000-$74,999$75,000-$99,999$100,000+ Annual Household Income	Some high schoolHigh school diploma or GEDAssociate's degreeBachelor's degreeMaster's degreeDoctoral degree Highest Level of Education	Native language only2345+ Number of languages you speak	Less than one year1-5 years6-10 years11-20 years20+ yearsAll my life Length of time in U.S.	Since 2003Since 2004Since 2005Since 2006Since 2007Since 2008Since 2009Since 2010 How long have you been part of EWI?

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3. Please provide the following information regarding your personal circumstances:

	How isolated do you feel?	Do you have a support network?	Do you receive public or charitable assistance?	Do you have health insurance?	What is your housing situation?	What is your immigration status?	What is your level of interest in becoming a U.S. citizen?
Select:	Not at all isolatedSomewhat isolatedVery isolated Please provide the following information regarding your personal circumstances:   Select:   How isolated do you feel?	Yes, have reliable supportYes, but limited supportNo support network Do you have a support network?	YesNo Do you receive public or charitable assistance?	YesNo Do you have health insurance?	ShelterSubsidized housingLive with family/friendsRent shared spaceRent own homeHomeowner What is your housing situation?	American-born U.S. citizenNaturalized U.S. citizenPermanent residentGreen cardWork visaStudent visaAsyleeRefugeeOther What is your immigration status?	Already am U.S. citizenSubmitted application for U.S. citizenshipPlan to apply for U.S. citizenshipNo interest in applying for U.S. citizenship What is your level of interest in becoming a U.S. citizen?

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4. Please assess your abilities in the following professional and personal areas:

	Poor	Fair	Good	Excellent
Creating a high-quality, marketable product	*Please assess your abilities in the following professional and personal areas: Creating a high-quality, marketable product Poor	Creating a high-quality, marketable product Fair	Creating a high-quality, marketable product Good	Creating a high-quality, marketable product Excellent
Making plans, and setting & achieving goals	Making plans, and setting & achieving goals Poor	Making plans, and setting & achieving goals Fair	Making plans, and setting & achieving goals Good	Making plans, and setting & achieving goals Excellent
Marketing & business skills	Marketing & business skills Poor	Marketing & business skills Fair	Marketing & business skills Good	Marketing & business skills Excellent
Presentation & public speaking skills	Presentation & public speaking skills Poor	Presentation & public speaking skills Fair	Presentation & public speaking skills Good	Presentation & public speaking skills Excellent
Networking & communicating with the public	Networking & communicating with the public Poor	Networking & communicating with the public Fair	Networking & communicating with the public Good	Networking & communicating with the public Excellent
English fluency	English fluency Poor	English fluency Fair	English fluency Good	English fluency Excellent
Self-confidence	Self-confidence Poor	Self-confidence Fair	Self-confidence Good	Self-confidence Excellent
Managing money	Managing money Poor	Managing money Fair	Managing money Good	Managing money Excellent

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5. Please provide the following information regarding your employment status:

	If you immigrated to the U.S., please describe your employment status before you came here	Current employment status	Hours work per week	What type of work do you do now?	What was your annual personal income before coming to EWI?	What is your annual personal income today?
Select:	Not employed, full-time studentNot employed, did not look for workNot employed, looked for workNonprofessional workProfessional in creative industriesProfessional, not in creative industriesNot applicable - did not immigrate to U.S. Please provide the following information regarding your employment status:   Select:   If you immigrated to the U.S., please describe your employment status before you came here	Not employed, full-time studentNot employed, not looking for workNot employed, looking for workEmployed, part-timeEmployed, full-timeSelf-employed Current employment status	0<1011-2021-3031-40>40 Hours work per week	Not employedMinimum wageNonprofessional, above minimum wageProfessional in creative industriesProfessional, not in creative industries What type of work do you do now?	$0<$5000$5,000-$9,999$10,000 - $19,999$20,000 - $29,999$30,000 - $39,999$40,000 - $49,999$50,000 - $74,999$75,000 - $99,999$100,000+ What was your annual personal income before coming to EWI?	$0<$5000$5,000-$9,999$10,000 - $19,999$20,000 - $29,999$30,000 - $39,999$40,000 - $49,999$50,000 - $74,999$75,000 - $99,999$100,000+ What is your annual personal income today?

6. In the past year, which of the following activities did you engage in to advance your career? Please check all that apply. If none of these apply, leave this question blank.

In the past year, which of the following activities did you engage in to advance your career? Please check all that apply. If none of these apply, leave this question blank.   Earned income by selling products under EWI label Earned income by selling own products via EWI-sponsored events and EWI channels Earned income by selling own products via events and channels not sponsored by EWI Earned income by teaching art or related creative skills at classes or workshops	Earned income by starting own business Hired new employees at my business Increased my income by starting employment Increased my income by changing jobs	Increased my income by getting a salary increase with my current employer Marketed my product line via an EWI-sponsored exhibition or channel Marketed my product line via an event or channel not sponsored by EWI Joined a professional organization
Other (please specify)

7. In the past year, which of the following community activities did you engage in? Please check all that apply. If none of these apply, leave this question blank.

In the past year, which of the following community activities did you engage in? Please check all that apply. If none of these apply, leave this question blank.   Volunteered with EWI Volunteered with a local organization (school, church, nonprofit, museum, etc.) that was not EWI Served as a mentor to others in EWI programs Served as a mentor to others, not in EWI programs Donated money or goods to EWI Donated money or goods to a charitable organization that was not EWI Participated with a social organization (e.g., sports league, book club) Participated with a church

Other (please specify)

8. In the past year, which of the following significant purchases were you able to make, that you were not able to make previously? Please check all that apply. If none of these apply, leave this question blank.

In the past year, which of the following significant purchases were you able to make, that you were not able to make previously? Please check all that apply. If none of these apply, leave this question blank.   Purchase a home Purchase a car Purchase a computer

Other (please specify)

9. In the next six months, do you plan to enroll in further training or education? If so, what kind? Please check all that apply.

In the next six months, do you plan to enroll in further training or education? If so, what kind? Please check all that apply.   ESL class Professional certification GED (High school diploma) Associate's degree Bachelor's degree Master's degree Doctoral degree

Other (please specify)

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10. How would you rate the overall impact of EWI on your personal and professional success?

	1 (No Impact At All)	2	3	4	5 (Moderate Impact)	6	7	8	9 (Very Strong Impact)	N/A (New to EWI)
Please select one:	*How would you rate the overall impact of EWI on your personal and professional success? Please select one: 1 (No Impact At All)	Please select one: 2	Please select one: 3	Please select one: 4	Please select one: 5 (Moderate Impact)	Please select one: 6	Please select one: 7	Please select one: 8	Please select one: 9 (Very Strong Impact)	Please select one: N/A (New to EWI)