ACE Enrollment Survey Question Title * 1. First and Last Name Question Title * 2. Date of Birth Question Title * 3. Home Address Question Title * 4. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305) Question Title * 5. Primary Phone Question Title * 6. Alternate Phone Question Title * 7. Email Question Title * 8. What is your gender? Female Male Other (specify) Question Title * 9. Are you of Spanish, Hispanic or Latino origin or descent? Not of Hispanic, Latino or Spanish Origin Hispanic, Latino or Spanish Origin Question Title * 10. Are you Black or African-American, White, American Indian or Alaskan Native, Asian, Native Hawaiian or other Pacific islander, or some other race? Black or African American White, Caucasian American Indian or Alaskan Native Asian or Pacific Islander Multiple Races Some other race (please specify) Question Title * 11. Are you an Immigrant? Yes No Question Title * 12. If yes, country of birth Question Title * 13. What language do you mainly speak at home? English Spanish Arabic French Somali Chinese Russian Vietnamese Some other language Question Title * 14. Which of the following best describes your current relationship status? Married, spouse present Married, spouse absent Widowed Divorced Separated Never married Question Title * 15. Which of the following categories best describes your employment status? Employed - Full Time Employed - Part Time Not employed Retired Other (please specify) Question Title * 16. What is your total household income? $0-$4,999 $5,000-$9,999 $10,000-$19,999 $20,000-$39,999 $40,000-$59,999 $60,000-$79,999 $80,000-$99,999 $100,000-$149,999 $150,000-$199,999 $200,000 or more Question Title * 17. What is your household size? Question Title * 18. Household Status Dependent Single, no dependents Single, head of household, one dependent Single, head of household, two or more dependents Couple, no dependents Couple, one dependent Couple, two or more dependents Question Title * 19. List household members names, relationship to you, gender, date of birth, race, if of Hispanic origin, and immigration status Question Title * 20. What is the highest level of education you have completed? Some high school High School graduate GED Some college Associates degree Diploma or certificate from Trade School Bachelor's degree Master's degree Professional degree Doctorate Question Title * 21. Are you a registered voter? Yes No Question Title * 22. Are you a veteran? Yes No Question Title * 23. I currently: Have a business idea Am ready to start my business Am interested in expanding my business Question Title * 24. Business Name Question Title * 25. Business Industry (check all that apply) Agriculture Construction Finance Manufacturing Arts/Creative Focus Retail Services Transportation/Public Utilities Wholesale Trade Other (please specify) Question Title * 26. Type of Business: For Profit Non-profit Question Title * 27. Business Description: Question Title * 28. Business Location: Home Storefront Market Food Truck/ Transient Vendor Other (please specify) Question Title * 29. Business Address (if different than home address): Question Title * 30. Business Start Date Question Title * 31. Business Registered with Secretary of State? Yes No Question Title * 32. Please enter EIN #, if none enter N/A Question Title * 33. Business Ownership, at least 51% (select all that apply) Female owned Male owned Minority owned Veteran owned Question Title * 34. Is business a full time commitment for you? Yes No Question Title * 35. Current # paid employees: Question Title * 36. How many employees are full time equivalents? Question Title * 37. Projected full time hires over the next 12 months? Question Title * 38. Is your business currently Losing money Breaking even Profiting Question Title * 39. Are you in need of any of the following Business Development Services? (Select all that apply) Marketing assistance Legal assistance Human resource assistance Business plan development Co-working space Access to skilled labor/employees Networking with other small businesses Capital (e.g., small business loan) Other (please specify) Question Title * 40. The following are my highest priority, three to five year business goals: 1. 2. 3. 4. 5. Question Title * 41. I grant Central Community House permission to use photographs and/or audio/video recordings of me for publicity purposes. This may include newspaper articles, community bulletins, CCH or United Way public service announcements, agency bulletin boards displays, etc. I understand that no compensation will be provided for use of any such images. Yes No Question Title * 42. Would you be willing to share a photo of yourself for the ACE program? If yes, please email to cmendez@cchouse.org. Yes No Question Title * 43. How did you hear about us? Question Title * 44. Please sign (type) your name here: Done
