GNE-MBDA COVID 19 Small Business Service Center

GNE-MBDA COVID 19 Small Business Service Center

Intake Form
Name

First Name Last Name
Business Name *
Business Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Business Phone Number *
Please enter a valid phone number.
Business Email *
example@example.com
Business Website
What industry is your business engaged in? *
Was your business affected by the COVID 19 Pandemic? *

Yes No
In the past 24 months, did you receive any of these government assistance programs for your business during COVID 19? *

SBA EIDL SBA PPP Other None
Are you MBE Certified? *
Please specify your business gross revenues for FY 2021.
Please specify your business gross revenues for FY 2020.
Please specify your projected gross revenues for FY 2022.
Does your business have a DUNS number? (Data Universal Numbering System) *
Does your business have a business plan? *
Pick a category that your business needs help with.
Should be Empty: