Amplify Queens StreetWise MBA Application Form

Amplify Queens StreetWise MBA Application
This application will take approximately 20 minutes to complete. Once you begin the application, you must complete all required fields; partially completed applications cannot be saved or submitted.
Applicant Name*

First NameMiddle NameLast Name
Business Name*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone*

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Email Address*
Website*
Industry*
Referred by*
Race/Ethnicity:*

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhitePrefer not to answerOther
Are you Hispanic/Latino?*

Yes, I am Hispanic/Latino.No, I am not Hispanic/Latino.Prefer not to answer
Please provide a brief description of your business:*
What month and year did you start/buy your business?*
Are you the 100% owner?*

YesNoOther
Number of full-time employees: *
Number of part-time employees: *
Estimated annual revenue from last calendar year: *
Where do you hope to see your business in three years?*
How do you plan to make time to participate in the program? *
This free program, valued at $15,000 is being provided to you by RDRC and Councilmember Selvena Brooks-Power so that you can grow and sustain your business.

Questions? Contact: Malcolm Harewood, mharewood@rdrc.org
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