NEA Intake Form

South Puget Intertribal Planning Agency

Entrepreneurial Programs - Native Entrepreneur Academy Intake Form
Name: First, Last
Date

MonthDayYear
Date
Phone Number
Email
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you enrolled in a federally recognized Tribe?

YesNo
Name of Tribe:
Upload a copy of your current Tribal Verification:

Cancelof
Thank you for your interest in participating in the Native Entrepreneur Academy You will create and develop a variety of tools, resources, and skills necessary to start/grow your business including expanding your network with other small business owners. Please enter your information below so we can help you better.
Have you ever owned a business/

YesNo
If yes, please answer the following questions:
Business Name:
Type of business/industry
How long has your business been open? Date opened

MonthDayYear
Date
Date closed

MonthDayYear
Date
Is the business still in operation?

YesNo
PIN/EIN:
How many employees?
Please share your successes in operating your business:
Please share any challenges that you are currently or have previously experienced operating your business:
What areas of your business do you need support with or are wanting to improve?
If no, please answer the following questions:
Have you started exploring self-employment opportunities?

YesNo
If no, what questions or potential challenges would you want to discuss with us as you get started?
When would you like to start your business? Within the next: What type of business would it be?

0- 6mo6mo-9mo9mo-12mo
What type of business would it be?
What type of products or services would you be providing/selling?
Briefly describe any challenges that may be preventing you from furthering your business ideas and/or starting your business:
What do you think it takes to be a successful business owner?
Personal Interests
Do you have any experience running a business for someone else? Please explain:
Do you have any hobbies you could consider turning into a small business? What are those hobbies?
Do you have any experience making or selling the item or service you have considered turning into a business?
Are you currently selling anything? If so what?

Rating Scale: Choose a number that best describes your interest in the following:

	No Interest (0)	Little Interest (1)	Somewhat Interested (2)	Neutrally Interested (3)	Somewhat Interested (4)	Highly Interested (5)
How interested are you in exploring or expanding your strengths and existing skills as they may relate to self-employment?
How interested are you in exploring your business idea and learning steps to develop it?
How interested are you in participating in a structured process for becoming an entrepreneur?
How interested are you in doing research and homework to explore and develop a successful business?

Technical Support/ Needs
Do you have reliable internet?

YesNo
Comments/Notes:
Do you have a computer or access to one?

YesNo
Comments/Notes:
Does your computer or your access to a computer have video and audio capabilities?

YesNo
Comments/Notes:
Commitment and Attendance
Are there any concerns you may have to be able to attend the Academy both in-person?

YesNo
If yes, please explain:
Are there any other schedule limitations or concerns you may have that would prevent you from wanting to attend the Academy? Blocks of time and prior commitments?

YesNo
If yes, please explain:
By signing this document, you adhere to WFD policy and commitment and expectations as a professional self-employment WFD client. No shows, a lack of active, and respectful partiipation may result in you not fully completing the workshop(s) or Academy and may void completion status and could result in sanction status.
Participant Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

South Puget Intertribal Planning Agency

Commitment and Attendance