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* 1. First and Last Name

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* 2. Date of Birth

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* 3. Home Address

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* 4. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305)

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* 5. Primary Phone

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* 6. Alternate Phone

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* 7. Email

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* 8. What is your gender?

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* 9. Are you of Spanish, Hispanic or Latino origin or descent?

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* 10. Are you Black or African-American, White, American Indian or Alaskan Native, Asian, Native Hawaiian or other Pacific islander, or some other race?

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* 11. Are you an Immigrant?

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* 12. If yes, country of birth

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* 13. What language do you mainly speak at home?

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* 14. Which of the following best describes your current relationship status?

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* 15. Which of the following categories best describes your employment status?

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* 16. What is your total household income?

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* 17. What is your household size?

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* 18. Household Status

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* 19. List household members names, relationship to you, gender, date of birth, race, if of Hispanic origin, and immigration status

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* 21. Are you a registered voter?

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* 22. Are you a veteran?

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* 23. I currently:

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* 24. Business Name

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* 25. Business Industry (check all that apply)

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* 26. Type of Business:

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* 27. Business Description:

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* 28. Business Location:

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* 29. Business Address (if different than home address):

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* 30. Business Start Date

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* 31. Business Registered with Secretary of State?

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* 32. Please enter EIN #, if none enter N/A

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* 33. Business Ownership, at least 51% (select all that apply)

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* 34. Is business a full time commitment for you?

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* 35. Current # paid employees:

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* 36. How many employees are full time equivalents?

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* 37. Projected full time hires over the next 12 months?

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* 38. Is your business currently

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* 39. Are you in need of any of the following Business Development Services? (Select all that apply)

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* 40. The following are my highest priority, three to five year business goals:

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* 41. How did you hear about us?

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