Community Navigators Pilot Program Client & Program Info Form

Community Navigators Pilot Program Client & Program Info Form

Please answer as honestly possible. This info will be used as a benchmark for your progress. This FREE program will provide valuable insight on starting, growing, and funding your small business.
Part I: Client Contact Information
Full Name*

First NameMiddle InitialLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Part II: Client Demographic Information
Race:*

American Indian or Alaska NativeAsianBlack or African AmericanWhiteNative Hawaiian or Other Pacific IslanderPrefer not to sayPrefer to self-describe
Ethnicity:*

Hispanic or LatinoNot Hispanic or LatinoPrefer not to sayPrefer to self-describe
What is your gender identity?*

FemaleMaleNonbinaryPrefer not to sayPrefer to self-describe
Do you identify as:*

IntersexTransgenderBothNeitherPrefer not to sayPrefer to self-describe
Do you identify as:*

BisexualGay/LesbianHeterosexualPrefer not to sayPrefer to self-describe
Military Service:*

No Military ServiceSpouse of Military MemberVeteranService-Disabled VeteranActive Duty
Do you consider yourself a person with a disability?*

YesNo
Part III: Client Business Information

This will be your baseline for the program, and we will continue to reevaluate your progress throughout the duration of the program. ***If you are not currently in business, report zeroes where applicable and report industry and demographic information as accurately as possible.
Are you currently in business?*

YesNo
Date business started:

MonthDayYear
Date
Name of business:
Taxpayer ID (if this is a social security number, please type 'SSN' after the number):
(Providing your Social Security Number is voluntary. SBA uses your Social Security Number to verify whether you received SBA assistance (financial or otherwise). Not providing your Social Security Number will not affect any right, benefit or privilege to which you are entitled.)
Legal Entity

Sole ProprietorshipCorporationS-CorporationPartnershipLLCOther
Number of part time employees:
Number of full time employees:
Enter the 6-digit code from the list or the lookup tool below:
Accommodation & Food Services 722511
Administrative & Support 561110
Agriculture 111419
Arts 711190
Construction 238990
Educational Services 611710
Entertainment & Recreation 713990
Finance & Insurance 523999
Fishing 114119
Forestry 113310
Health Care & Social Assistance 621399
Information 519290
Mgmt of Companies & Enterprises 551114
Manufacturing 339999
Mining 212390
ProfessionalScientific/Technical Services 541990
Public Administration 921190
Real Estate, Rental, & Leasing 531210
Retail Trade 459999
Transportation & Warehousing 485999
Utilities 221320
Waste Mgmt & Remediation Services 562920
Wholesale 424990
Other Services (except Public Admin) 813990
Gross Revenue
How much money did your business bring in last year?
Net profit or loss:
Gross revenue minus business expenses for the year
Have you applied for or received any SBA services in the last 5 years?

YesNo
If yes, which program(s) (check all that apply):

Paycheck Protection Loan/ForgivenessCovid Economic Injury Disaster LoanRestaurant Revitalization FundShuttered Venues GrantOther SBA Disaster Loans7(a) or 504 Guaranteed Loan8(a) CertificationOther Contraction CertificationOther, (specify)
Do you conduct business in a language other than english?*

YesNo
Is this a woman-owned business?*

YesNo
Part IV: Nature of Assistance:
What is the dollar amount of loan/grant sought?*
What type of assistance are you seeking?*

Paycheck Protection Loan/ForgivenessCovid Economic Injury Disaster LoanRestaurant Revitalization FundShuttered Venues GrantOther SBA Disaster Loans7(a) Loan504 LoanMicroloanExport LoanOther LoanState/Local GrantOther GrantSBA Contracting CertificationAssistance Starting a BusinessOther, (specify)
Are you requesting language assistance?*

YesNo
What other classes would you find valuable? Select all that apply.

Legal requirements for starting a businessRecordkeeping and organizing business financesCricut t-shirt design classGuided business planningPitching/promoting your businessGetting your business online and socialMarketing basicsSocial media marketing basicsEmail and SMS marketingPricing models for successful businessesBrand audit and recommendations
I request business counseling service from the Small Business Administration (SBA) or Community Navigator. I agreed to cooperate should I be selected to participate in surveys designated to evaluate SBA services. I permit SBA or its agent the use of my name and address for SBA surveys and information mailings regarding SBA products and services (select below). I understand that any information disclosed will be held in strict confidence. (SBA will not provide your personal information to commercial entities). I authorize SBA to furnish relevant information to the assigned management counselor(s). I further understand that the counselor(s) agrees not to: 1) recommend goods or services from sources in which he/she has an interest, and 2) accept fees or commissions developing from this counseling relationship. In consideration of the counselor(s) furnishing management or technical assistance, I waive all claims against SBA personnel, and that of its Community Navigator and host organizations, arising from this assistance.

Use of Information Collected: Information collected from SBA Form 3516 will only be published in summary or aggregate form as a means of providing SBA management officials, Congress, the White House and OMB with reports on program activity and participant outcomes. SBA expects to produce annual reports to the White House, OMB and Congress on the impact of the Community Navigator Pilot Program leveraging aggregate data to illustrate program objectives and outcomes have been met. Please note, SBA may match Form 3516 information with other data sets for program evaluation purposes. In all cases, SBA will protect individual privacy and confidentiality and only aggregate and summary data would be published.
Do you agree to the terms you just read?*

YesNo
Today's date*

MonthDayYear
Date
Client Signature*

Clear
Should be Empty:

Community Navigators Pilot Program Client & Program Info Form

Part I: Client Contact Information

Part II: Client Demographic Information

Part III: Client Business Information

Part IV: Nature of Assistance: