EMPOWERMENT CHECK-IN

Date / Time

Date

Time

Business Name (Required)

Owner(s) Name(s)

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email

Confirm Email

Website (if available)

Business Structure

"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?

Industry (excluding record labels, investor owned real estate, single non – franchise restaurants)

If "Other" specify the Industry

Confirm your NAICS 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

Number of Employees

Annual Revenue (Last Fiscal Year)

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 _________?

Is your business at least 51% owned by any of the following?

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?

What type of debt do you currently have?

If "Other" please speciffy

How do you currently track financials?

What accounting software do you use?

How often do you monitor and reconcile you income and expenses?

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?

0 of 175 max words.

How did you hear about our initiative?

If "Other" how did you hear about us?