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EMPOWERMENT CHECK-IN
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Date / Time
*
Date
Time
Business Name (Required)
*
Owner(s) Name(s)
*
Address
*
Address Line 1
Address Line 2
City
— Select state —
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
*
Email
*
Email
Confirm Email
Website (if available)
Business Structure
Other ________________
Sole Proprietor
LLC
Corporation (S-Corp / C-Corp)
Partnership
Non-Profit
Other
"Other" Enter Business Structure
What percentage of the business do you own?
*
Additional Owner(s) Name (s) + Percentage of Ownership
When was the last time you filed business taxes?
Filed for 2024 (Most Recent Year)
Filed for 2023 (Last Year)
Filed for 2022 or Earlier
I have never filed business taxes
Prefer Not to Say
Industry (excluding record labels, investor owned real estate, single non – franchise restaurants)
Commercial Real Estate & Development
Construction & Development
Education & Workforce Development
Facilities Management
Government Contracting & Defense
Healthcare & Medical Services
Hospitality & Event Services
Manufacturing
Professional Services
Renewable Energy & Sustainability
Retail & E-Commerce
Technology & IT Services
Transportation & Logistics
Wholesale Trade & Distribution
Other
If "Other" specify the Industry
Confirm your NIACS Code (s)
*
You can find your NAICS code on your business tax return, at www.naics.com, or on the U.S. Census Bureau website. You can also ask ChatGPT: “What is the NAICS code for [your industry]?”
Number of Years in Business
Startup (Less than 1 year)
1-3 Years
3-5 Years
5-10 Years
10-20 Years
20 +
Number of Employees
1 (Self-Employed
2-10 Employees
11-25 Employees
25-50 Employees
50 + Employees
Annual Revenue (Last Fiscal Year)
$100,000 – $250,000
$250,000 – $500,000
$500,000 – $1M
$1M- $5M
$5M- $10M
Over $10M
Do you have financial statements for the last _____ ?
12 months
24 months
3 years
Don’t have any recent Financials
Please Explain
"Do you work with a _________?
Accountant
Bank Relationship Manager
Certified Financial Planner
CPA
Bookkeeper
Estate Planner
Investment Advisor
None of the Above
levies, you type
Is your business at least 51% owned by any of the following?
Minority-Owned
Women-Owned
Veteran-Owned
Service-Disabled Veteran-Owned
LGBTQ+-Owned
Do you have any levies, judgments, liens, or other legal issues affecting your business?
YES
NO
If Yes, please provide details:
Do you currently have business debt or outstanding loans?
Yes, under $50K
Yes, between $50K – $100K
Yes, between $100K – $200K
Yes, between $200K- $500k
Yes, between $500k- $750k
Yes, between $750k- $1M
Yes, $1M +
What type of debt do you currently have?
Line of Credit
SBA Loan
Bank Loan
Merchant Cash Advance
Vendor Credit Terms
Other
If "Other" please speciffy
How do you currently track financials?
I check my bank account manually
I use accounting software (QuickBooks, Xero, FreshBooks, etc.)
I track expenses in Excel/Google Sheets
I work with a bookkeeper/accountant
I don’t track my finances
What accounting software do you use?
How often do you monitor and reconcile you income and expenses?
Yes, I track it weekly
Yes, I track it Monthly
Yes, I track it Quarterly
No, I do not track it
Do you have a business plan or documented strategy for growth?
YES
NO
If Yes, please provide details:
Have you registered in SAM.gov?
YES
NO
Have you applied for business funding or grants before?
Yes, and I received funding
Yes, but I was denied
No, I have not applied
If Yes, please provide details:
Is your business certified as any of the following?
Small Business Enterprise (SBE)
Local Business Enterprise (LBE)
Minority Business Enterprise (MBE)
Women-Owned Business Enterprise (WBE)
Disadvantaged Business Enterprise (DBE)
Veteran-Owned Business (VOB)
Not yet certified
Have you bid on or been awarded a government contract?
Yes, I have won a contract
Yes, but I did not win the bid
No, I have not applied
Would you like assistance with certification & procurement?
YES
NO
What type of funding are you seeking?
Grant
Loan
Line of Credit
If seeking capital, how would you use the funds?
Working Capital (Day-to-Day Operations)
Purchase Equipment / Machinery
Expand Business Location / Open a New Location
Hire More Employees
Marketing & Advertising
Purchase Inventory / Supplies
Pay Off Existing Business Debt
Technology Upgrades (Software, IT, Security)
Other (Please Specify)
If "Other" Please specify How you will use the funds?
What are the biggest challenges your business faces right now?
Business structure or legal compliance issues
Cash flow issues
Difficulty getting government or corporate contracts
Hiring & workforce development
Lack of funding/capital
Marketing & customer acquisition challenges
Need help with financial management & bookkeeping
Other
If "Other" Enter biggest challenges
What are your top three business goals for the next 90 days?
What are your top three business goals for the next 6 months??
What are your top three business goals for the 12 months??
What are your top three business goals for the 5 years?
What type of support would be most valuable for your business?
Access to funding & business loans
Business certification & contract opportunities
Financial coaching & cash flow management
Business strategy & growth planning
Networking & strategic partnerships
What makes your business a strong candidate for our initiative?
*
How did you hear about our initiative?
Referral
Social Media
Website
Business Networking Event
Other
If "Other" how did you hear about us?
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