DAWN Client Intake Survey

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* 1. First Name:

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* 2. Last Name:

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* 3. Email:

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* 4. Phone:

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* 5. Street Address:

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* 6. City:

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* 7. State:

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* 8. Zip Code:

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* 9. County:

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* 10. What is your age?

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* 11. What is your gender identity?

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* 12. What race or ethnicity best describes you? Please select all that apply:

Asian

Black/African American

Hispanic/Latino

Indigenous, Native American, American Indian, or Alaskan Native

White or Caucasian

Native Hawaiian

Other Pacific Islander

Prefer not to say

Other (please specify)

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* 13. Are you a member or descendant of a Native Nation?

Yes

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* 14. If yes, which Native Nation(s)? Please select all that apply:

Bois Forte Band of Chippewa

Fond du Lac Band of Lake Superior Chippewa

Grand Portage Band of Lake Superior Chippewa

Leech Lake Band of Ojibwe

Mille Lacs Band of Ojibwe

Red Lake Nation

White Earth Nation

Lower Sioux Indian Community

Prairie Island Indian Community

Shakopee Mdewakanton Sioux Community

Upper Sioux Community, Pezihutazizi Oyate

Other (please specify)

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* 15. What is your approximate annual household income?

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* 16. Do you identify as a veteran?

Yes

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* 17. Do you identify as a person living with a disability?

Yes

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* 18. Is English your first language?

Yes

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* 19. If English is not your first language, would you like access to interpreter services?

Yes

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* 20. Describe your idea or business:

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* 21. At what stage is your idea or business?

Idea Stage: I've got an idea that I haven’t shared or started working on yet.

Concept Stage: I’ve shared my idea with others and began defining problems and solutions.

Validation Stage: I’m actively engaging the marketplace to confirm the problem/solution fit, and I have generated revenue.

Launch Stage: I have confirmed my business or solution model, and it is operational. I am actively seeking customers.

Growth Stage: I have a solid customer base and am ready to expand my business.

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* 22. Business Name (if applicable):

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* 23. Website (if applicable):

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* 24. Current number of employees (if applicable):

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* 25. How can we help start your business? Please select all that apply:

Open-ended curriculum to help you build on your idea

Access to early-stage funding and capital providers

Access to networks and mentoring supports

Access to Technical Assistance (assistance with business plans, creating projects, etc.)

Grant Application Assistance

Other (please specify)

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* 26. How can we help grow your business? Please select all that apply:

Industry-specific curriculum to help you grow your business

Access to sophisticated investor networks

Access to networks of specialized experts to help scale your business

Access to technical assistance (assistance with business plans, creating projections, etc.)

Grant application assistance

Other (please specify)

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* 27. On a scale of 1 - 10, how connected do you feel to the community where your business operates, or you plan to operate? (1 = Not at all connected, 10 = Extremely connected)

Clear

i We adjusted the number you entered based on the slider’s scale.

DAWN Client Intake

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* 1. First Name:

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* 2. Last Name:

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* 3. Email:

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* 4. Phone:

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* 5. Street Address:

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* 6. City:

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* 7. State:

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* 8. Zip Code:

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* 9. County:

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* 10. What is your age?

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* 11. What is your gender identity?

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* 12. What race or ethnicity best describes you? Please select all that apply:

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* 13. Are you a member or descendant of a Native Nation?

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* 14. If yes, which Native Nation(s)? Please select all that apply:

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* 15. What is your approximate annual household income?

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* 16. Do you identify as a veteran?

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* 17. Do you identify as a person living with a disability?

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* 18. Is English your first language?

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* 19. If English is not your first language, would you like access to interpreter services?

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* 20. Describe your idea or business:

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* 21. At what stage is your idea or business?

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* 22. Business Name (if applicable):

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* 23. Website (if applicable):

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* 24. Current number of employees (if applicable):

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* 25. How can we help start your business? Please select all that apply:

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* 26. How can we help grow your business? Please select all that apply:

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* 27. On a scale of 1 - 10, how connected do you feel to the community where your business operates, or you plan to operate? (1 = Not at all connected, 10 = Extremely connected)

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* 28. Other information you’d like us to know?