MBDA EWOC Business Center

First Name

Last Name

First & Last Name

Email

Confirmation EmailRe-enter Email to Confirm

Your Phone Number

Area CodePhone Number

Gender

Race/Ethnicity (check all that applies)

Age:

Residency/Citizenship:

Other

Veteran Status (check all that applies)

Name of Business

Doing Business As (DBA) Name, if any:

Business Phone Number (if different from your phone number above)

Please enter a valid phone number.Format: (000) 000-0000.

Business Street Address

Second Line for Business Street Address (if space needed)

City

U.S. Territory/State

Zip Code

Business location type (check all that applies):

Other

Business Website:

Business Social Media Handles (e.g., Facebook, Instagram, LinkedIn, Twitter)

Business Entity Type

How long has your business been in business?

What is your current business title (for example: President, Managing Member, Partner):

Who is second in command? (Please enter name and title below):

Is your business 51% woman-owned?

Business Ownership: What percent of your business is Male owned?

Business Ownership: What percent of your business is Female owned?

Business Ownership: What percent of your business is owned by Non-Binary/Other (e.g., legal entity/etc.)?

Business Ownership: What percent of your business is Female owned?

Business Ownership: What percent of your business is owned by Non-Binary/Other (e.g., legal entity/etc.)?

Officers/Partners/Members in your business (please list name, percentage and title for each person below)

Is your business registered with State of Hawaii Department of Commerce & Consumer Affairs (DCCA)?

DCCA business registration date:

Date

Is your business registered in an U.S. state/territory (not counting Hawaii)?

Business registration/general excise tax number:

Articles of incorporation date (if any):

Date

Federal tax ID number (FEIN/EIN):

DUNS No. (if any):

SAM Registration date (if any):

Date

Products or services you sell/offer and each NAICS CODE that goes along with each product.

Annual Revenue 2019 (This information will help us better serve your business; we will keep this information confidential on a need-to-know basis within our Center)

Annual Revenue 2020 (This information will help us better serve your business; we will keep this information confidential on a need-to-know basis within our Center)

Does your business conduct transactions online (for example, offer services/goods with online purchase option)?

Other

Is your business currently exporting (in other words, selling goods/services outside of the U.S.)?

Please indicate the current industry/industries for your business (check all that applies):

Please briefly describe your type or nature of business, such as types of services or goods offered. Do not disclose any confidential or proprietary information (For example: Marketing consulting firm focused on helping fashion designers promote their goods in Hawaii and on the West Coast)

Referred to EWOC by (check all that applies)

Which of the following YWCA O'ahu programs or services have you or your business received or participated in before? (check all that applies)

Other

Are you interested in our free workshops/courses? (check all that applies):

Are you interested in our free one-on-one BUSINESS counseling (two 1-hour sessions)? Select 2 - 3 topics below for the first session. We will contact you via phone/email to schedule:

Other

Please identify your one or two GOAL(s) for BUSINESS counseling. For example, a goal could be "compete for more corporate contracts", "ramp up marketing for my business" or "explore exporting opportunities" (If you are not requesting business counseling, please put "Not Applicable" below):

Please briefly describe the 3 - 5 specific topic(s)/question(s) you'd like to discuss for BUSINESS counseling. Be as specific as you can be since this will make the best use of the 1-hour session and allow the counselor to best prepare. (If you are not requesting business counseling, please put "Not Applicable" below):

Describe your experience with business accounting (check all that applies, even if you are requesting business counseling):

Please describe below the type of ACCOUNTING software or system you are currently using (even if you are requesting business counseling). Please be as specific as you can to maximize your counseling session(s). For example, you could list "QuickBooks for all bookkeeping" or "all paper documents for receipts and Excel for calculations" or whatever best describes your situation.

Are you interested in our free one-on-one FINANCIAL counseling (two 1-hour sessions)? Select 2 - 3 topics below for the first session. We will contact you via phone/email to schedule:

Other

Please identify your one or two GOAL(s) for FINANCIAL counseling. For example, a goal could be "learn the basics of financial reports", "improve cash management", "improve accounting system or software" or "learn loan application tips". (If you are not requesting financial counseling, please put "Not Applicable" below):

Please briefly describe the 3 - 5 specific topic(s)/question(s) you'd like to discuss for FINANCIAL counseling. Be as specific as you can be since this will make the best use of the 1-hour session and allow the counselor to best prepare. (If you are not requesting financial counseling, please put "Not Applicable" below):

Please briefly describe what has been the biggest challenge with MARKETING your business? Be as specific as you can be to maximize your session with our counselor.

Total employees for your business:

How many are full-time employees?

How many are part-time employees?

How many are temporary employees?

How many are female employees?

How many are male employees?

Your Current Business Certifications? (check all that applies)

Other

I permit the Business Center or its agent the use of my name, my business name and/or city and state, as well as my likeness, images and quotes (if any), for Business Center emails, flyers, social media, marketing or mailings to promote the Business Center's services to the community and other local businesses. PLEASE NOTE that if you select "No" below and participate in a Zoom/online platform or in-person event that is being recorded or photographed, you may need to leave the room or manually turn off your own video and name settings - this is beyond the Business Center's control.

Business Center Enews/Eblasts: Check the "Yes" box below if you would like to receive enews/eblasts from: MBDA Enterprising Women of Color Business Center at YWCA O'ahu, 1040 Richards Street, Suite 301, Honolulu, HI, 96813 United States, www.ywcaoahu.org/mbda-ewoc. Your email address will only be used for official Business Center purposes and will not be provided to unauthorized third-parties. Note: You can revoke your consent to receive emails at any time by clicking unsubscribe at the footer of the email or emailing the Business Center at mbdaewoc@ywcaoahu.org with the subject "Unsubscribe". We will then use reasonable efforts to remove you from future enews/eblasts within 10 days after we receive your email to unsubscribe. PLEASE NOTE that regardless of your selection below the Business Center will send you emails about this Intake Form and/or trainings/other services if you indicated interest.

Please read the general terms & conditions below. If you are in agreement, sign where indicated.

Intake Form and information: I hereby submit this Intake Form ("Intake Form") to MBDA Enterprising Women of Color Business Center at YWCA O'ahu ("Business Center") for its review and consideration. I agree to: (1) provide additional information or complete any additional forms if needed for the services (such as non-disclosure agreements to protect any potential confidential information that may be shared among participants); and (2) cooperate should I be selected to participate in surveys designed to evaluate the Business Center's services. I understand that any information disclosed will be held in confidence. The Business Center will not provide my personal information to commercial or third-party entities, unless required to by U.S. Department of Commerce Minority Business Development Agency ("MBDA") laws, rules, regulations or grant requirements.

Authorized individuals/entities: I hereby authorize the Business Center to furnish relevant information to authorized Business Center employees, independent contractors or agents, as well as MBDA. I further understand that Business Center employees, independent contractors and agents agree not to: (1) recommend goods or services from sources in which he/she/it has an interest; and (2) accept fees or commissions developed from this Business Center relationship if it is within the scope of his/her/its work with the Business Center.

Waiver; Own Due Diligence; No Warranties: In consideration of YWCA O'ahu, the Business Center, MBDA and/or the Business Center's third-party resource partners/collaborating organizations (including but not limited to their respective employees, independent contractors, volunteers and agents) offering/furnishing referrals, training, management or technical assistance, I waive all claims, causes of action, demands and damages (including but not limited to general, compensatory, special, punitive and consequential damages) of any type or kind, whether known or unknown at this time, against YWCA O'ahu, the Business Center, MBDA, third-party resource partners/collaborating organizations (including but not limited to their respective employees, officers, directors, boards, independent contractors, volunteers and agents) arising from, related to or in connection with the referrals, training, management, counseling, referral or technical assistance offered/provided. There are no express or implied promises or warranties of any kind (including but not limited to warranty of merchantability or fitness). I understand and agree that the assistance is provided on an as-is basis; and I will conduct my own due diligence to determine the suitability/appropriateness of the assistance for me or my business.

No Representations or Professional Services Provided: I understand and agree that the Business Center does NOT represent me or my business, as such, the referral, assistance and/or counseling provided is for informational purposes only and provided for convenience only. NO professional services are provided to me or my business, including but not limited to professional accounting, financial, legal or business advice. I am solely responsible for the results or consequences of the course of action I may or may not choose to take based on the referral, assistance and/or counseling.

Use of Information: The information in this Intake Form is to be provided by individuals and business seeking training, management or technical assistance services from the Business Center. The information is collected to help the Business Center's continuing improvement of training, resources and counseling programs, to ensure effective oversight and management of entrepreneurial development programs and grants, and/or to meet reporting requirements.

Electronic Signature: I agree that I have provided information to the best of my knowledge. I consent and agree that my use of a key pad, mouse or other device to select an item, and submit this Intake Form constitutes my signature, acceptance and agreement as if actually signed by me in writing. Further, I agree that no certification authority or other third-party verification is necessary for the validity of my electronic signature; and that the lack of such certification or third-party verification will not in any way affect the enforceability of my signature with respect to this Intake Form. This Intake Form shall be governed by and interpreted under Hawaii and federal law.

Signature: My typed-in signature below acknowledges that: (1) I have submitted information in this application to the best of my knowledge; and (2) I have read and will comply with the general terms & conditions above.

EWOC Intake Form