REI WBC Business Assessment Form

Today's Date *

Month Day Year
Date
Type of Session *

Telephone Online
I am registered for an upcoming WBC workshop. *

Yes No
Workshop Title
General Information
Your Name *
Email Address *
Phone Number *
Mailing Address *
County *
It's okay to contact me in the future.
What services are you needing help with? *

Start‐Up Assistance - (How do I start a small business?) Human Resources Managing Employees Marketing / Sales (promotion, market research, pricing, etc.) Buying / Selling a Business Business Plan Customer Relations Tax Planning Franchising Financing / Capital (such as applying for a loan, building equity capital) E-commerce (using the Internet to do business) Woman Owned Small Business Certificate Government Contracting (HUB Zone, 8a, etc.) Legal Issues Technology / Computers Managing a Business Cash Flow Management Business Accounting / Budget International Trade
Is your request for assistance related to COVID-19 recovery? *

Yes No
Referred by? (Check all that apply) *

SBA District Office SBA Website Lender Local Economic Development Office WBC Client Other Business Owner Social Media/Internet TV/Radio/Newspaper/Magazine Educational Institution Chamber of Commerce Small Business Development Center SCORE Chapter VBOC Boots to Business Word of Mouth
WBC Client
Other Business Owner
I request business counseling service from REI Women’s Business Center. *

Yes No
Demographic Information
Race (Mark one or more) *

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White
Ethnicity *

Hispanic or Latino Not Hispanic or Latino
Gender *

Female Male
Do you consider yourself a person with a disability? *

Yes No
Military Status *

Non-Military Active Duty Member of Reserve or National Guard National Guard Service Veteran Service-Disabled Veteran Spouse of Military Member
What was your annual household income for the most recent calendar year? *
What is your current household size? (Including yourself) *
Employment, Income and Benefits Information
Employment Status (check all that apply) *

Working in my business (self‐employed) Working for someone else Not 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 idea Pre‐business (no sales) with multiple business ideas Start‐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) *

Yes No
Business Name
Business Address

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

Construction Educational Services Accommodation & Food Services Agriculture, Forestry, Fishing & Hunting Information Finance and Insurance Arts, Entertainment & Recreation Management of Companies & Enterprises Mining Manufacturing Health Care & Social Assistance Other Personal Services (except Public Administration) Retail Trade Public Administration Real Estate & Rental & Leasing Professional, Scientific & Technical Services Utilities Wholesale Trade Transportation & Warehousing Waste Management & Remediation Services
Business legal structure

Sole Proprietorship Corporation LLC S‐Corporation Partnership
Business Description
Are you currently exporting?

Yes No
What month and year did you start your business?

Month Day Year
Date
What percentage of your company is female owned?
Business Status

Full-time Part-time Seasonal
Do you conduct business online?

Yes No
Are you a home based business?

Yes No
Are you 8(a) certified?

Yes No

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?

Yes No
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 Program I am/my firm is located in a HUBZone My firm is an Economically Disadvantaged Women‐Owned Small Business 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 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 I 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 *

Clear
Date *

Month Day Year
Date
Should be Empty:

General Information

Demographic Information

Employment, Income and Benefits Information

Business Information

Please Initial All That Apply