REI WBC Business Assessment Form

Today's Date*

MonthDayYear
Date
Type of Session*

TelephoneOnline
I am registered for an upcoming WBC workshop.*

YesNo
Workshop Title
General Information
Your Name*
Email Address*
Phone Number*
Mailing Address*
County*
It's okay to contact me in the future.
Demographic Information
Race (Mark one or more)*

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite
Ethnicity*

Hispanic or LatinoNot Hispanic or Latino
Gender*

FemaleMale
I am a single mother or single woman household.*

YesNo
Do you consider yourself a person with a disability?*

YesNo
Military Status*

Non-MilitaryActive DutyMember of Reserve or National GuardNational Guard ServiceVeteranService-Disabled VeteranSpouse of Military Member
What was your annual household income for the most recent calendar year?*
What is your current household size? (Including yourself)*
Is your request for assistance related to COVID-19 recovery?

YesNo
What services are you needing help with?*

Start‐Up Assistance - (How do I start a small business?)Human ResourcesManaging EmployeesMarketing / Sales (promotion, market research, pricing, etc.)Buying / Selling a BusinessBusiness PlanCustomer RelationsTax PlanningFranchisingFinancing / Capital (such as applying for a loan, building equity capital)E-commerce (using the Internet to do business)Woman Owned Small Business CertificateGovernment Contracting (HUB Zone, 8a, etc.)Legal IssuesTechnology / ComputersManaging a BusinessCash Flow ManagementBusiness Accounting / BudgetInternational Trade
Referred by? (Check all that apply)*

SBA District OfficeSBA WebsiteLenderLocal Economic Development OfficeWBC ClientOther Business OwnerSocial Media/InternetTV/Radio/Newspaper/MagazineEducational InstitutionChamber of CommerceSmall Business Development CenterSCORE ChapterVBOCBoots to BusinessWord of MouthOther
WBC Client
Other Business Owner
I request business counseling service from REI Women’s Business Center.*

YesNo
Employment, Income and Benefits Information
Employment Status (check all that apply)*

Working in my business (self‐employed)Working for someone elseNot employed (whether seeking or not seeking employment)
Business Information - Which of the following BEST describes your current business status?*

Pre‐business (no sales) with one business ideaPre‐business (no sales) with multiple business ideasStart‐up (in business less than 1 year with sales)Ongoing (in business more than 1 year with sales)
Business Information
Are you currently in business? (If NO, Skip To End of Survey)*

YesNo
Business Name
Business Address

Check if same as home address
Business Phone
DUNS #
Business Email
Website
Type of Business (choose primary category)

ConstructionEducational ServicesAccommodation & Food ServicesAgriculture, Forestry, Fishing & HuntingInformationFinance and InsuranceArts, Entertainment & RecreationManagement of Companies & EnterprisesMiningManufacturingHealth Care & Social AssistanceOther Personal Services (except Public Administration)Retail TradePublic AdministrationReal Estate & Rental & LeasingProfessional, Scientific & Technical ServicesUtilitiesWholesale TradeTransportation & WarehousingWaste Management & Remediation Services
Business legal structure

Sole ProprietorshipCorporationLLCS‐CorporationPartnershipOther
What is the current stage of your business?

PreventureGrowthStart-UpMaturityEarly StageRevitalizationOther
Company NAICS Code(s):
Business Description
Are you currently exporting?

YesNo
What month and year did you start your business?

MonthDayYear
Date
What percentage of your company is female owned?
Business Status

Full-timePart-timeSeasonal
Do you conduct business online?

YesNo
Are you a home based business?

YesNo
Are you 8(a) certified?

YesNoUnsure

Number of employees besides yourself

	# of Employees
Full‐time
Part‐time
Seasonal
# engaged in exporting

Number of contractors besides yourself

	# of Contractors
Full‐time
Part‐time
Seasonal
# engaged in exporting

For the last 12 months in business, what was your gross revenue/sales?
For the last 12 months in business, what was your profit (+) / loss (-)?
Sales related to exporting

For your last 12 months in business, what were your


Number of New Employees
Number of Employees Retained
Decrease in Employees

Do you plan to pursue capital for your business in the next six months?

YesNo
Please Check All That Apply

I hereby certify that my business meets the size standards established for small businesses as set forth in the regulations at 13 C.F.R. Part 121.My firm is a participant in SBA’s 8(a) Business Development ProgramI am/my firm is located in a HUBZoneMy firm is an Economically Disadvantaged Women‐Owned Small BusinessI am/my firm is located in an area of high unemployment, meaning that my county’s OR metropolitan area’s annualized unemployment rate exceeds the national annualized unemployment rate.I am an individual with a low income, or my firm is majority‐owned by one or more individuals each with a low income. "Low income” means an individual whose income does not exceed the following levels, as reflected in last year’s tax return: • $ 42,400 for metropolitan areas • $ 31,300 for non‐metropolitan areasI am Native American or Alaska Native
Please Initial All That Apply
I hereby certify that my business meets the size standards established for small businesses as set forth in the regulations at 13 C.F.R. Part 121.
I am/my firm is located in a HUBZone
I am/my firm is located in an area of high unemployment, meaning that my county’s OR metropolitan area’s annualized unemployment rate exceeds the national annualized unemployment rate.
I am Native American or Alaska Native
My firm is a participant in SBA’s 8(a) Business Development Program
My firm is an Economically Disadvantaged Women‐Owned Small Business
I am an individual with a low income, or my firm is majority‐owned by one or more individuals each with a low income. "Low income” means an individual whose income does not exceed the following levels, as reflected in last year’s tax return: • $ 42,400 for metropolitan areas • $ 31,300 for non‐metropolitan areas
Signature*
Date*

MonthDayYear
Date
Should be Empty:

General Information

Demographic Information

Employment, Income and Benefits Information

Business Information

Please Initial All That Apply