MyBusiness Startup to Service: Intake Form

Application Deadline for Fall Session is August 31st, 2016

This program includes intensive entrepreneurial training and is designed for women in the early stages of starting a service-based business. The sessions are designed to hone one's business concept, understand and prepare financials, register your business, and learn to effectively pitch your business. The program will be facilitated by successful entrepreneur and local businesswoman Denise DeSimone, chairman of C-Leveled. At the end of this program, participants will have a pitch deck, a registered business, a vision for their business moving forward, and a working business plan. Participants will also have access to networking opportunities and educational resources through the Center for Women’s Entrepreneurship.

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* 1. Tell us about yourself:

First and Last Name:

Email Address:

Phone Number:

Mailing address (include city, state, zip):

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* 2. Tell us about your business:

Have you started the business for which you are seeking assistance?

Please provide your business name:

Please provide your business address:

Please provide your business website (if any):

Please provide 1-3 primary markets for your business:

Please provide your business description and type of industry:

Please provide the number of employees (excluding yourself):

If you haven't started a business yet, please explain your business idea or concept:

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* 3. Please provide a brief description of your professional background, including any entrepreneurial experience and previous experience you have working with start-ups.

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* 4. Tell us more about what you have accomplished so far:

Are you interested in applying to an accelerator?

If yes, when and why did you apply?

If you applied and weren't selected, will you apply again?

Have you received any external funding for your business to date? (loans, grants, crowdfunding etc)

If yes, what kind of funding did you receive and how did you utilize that funding?

Are you interested in external funding? What kind, and what would you like to accomplish with that funding?

What are your growth goals; how large would you like to become in terms of employees, geographic reach, and/or revenue?

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* 5. Please select three main areas in which you feel your business needs the most assistance.

Strategy (vision, mission, planning)

Finance (financial systems, bookkeeping, budgeting, projections, turnover, cash flow)

Capital (equity and debt financing to grow your business)

Service Development (new or better services)

Marketing/Communications (customer loyalty/base, new markets, visibility, social media)

Sales (sales volume, merchandising, pricing, margins)

Operations and/or Production (production methods, administration, waste, downtime, inventory, Six Sigma)

Globalization (outsourcing)

Legal (reorganizing, drafting contracts, certifications, regulatory compliance)

Intellectual Property (patents, copyrights, trademarks)

Consumer/Market Research (focus groups, consumer feedback)

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* 6. Do you have any other comments, questions, or concerns?

The Center for Women's Entrepreneurship at Chatham University understands that any information you disclose in this form is both confidential and proprietary and will only be used for evaluating your entry into the MyBusiness Startup to Service Program.