SELF Program Applicant Profile Form

Microenterprise Class Participant Profile

Please fill out the form carefully to apply
Participant's Name*

First NameMiddle Initial (if applicable)Last Name
Participant's Ownership Title

TitleOther Title (if applicable)
Birth Date (optional)

MonthDayYear
Gender (optional)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary E-mail for Class Use*
example@example.com
Mobile Number*
Secondary Phone Number
Other Contact Number
Company Name
What is the nature of the business / organization that you will start or have started?*
How many years in this business or any other business you have owned?*
What are your annual sales?
If your sales are less than $10,000, please choose one of the options below:
What percentage of your company is minority or woman owned?*
Please List All Business and Personal Certifications, if none enter NA
What kind of financial statements do you have?

Company preparedAccountant CompilationCPA AuditedNone or I do not know
What kind of accounting software do you use?

QuickbooksPeachtreeSpreadsheetMy accountantNone or I do not know
Have you ever completed a business plan?*

YesNoNot Sure
What do you consider your most important personal and/or business accomplishment to date? Why? What leadership role did you play in achieving the accomplishments?*
What do you consider your most serious problem related to launching or growing your business, and what do you think should be done about it?*
Why are you a good candidate for SELF's Microenterprise class?*
What outcomes do you expect to gain from the Microenterprise class? List three (3) in order of importance to you.*
Are you willing to provide candid feedback regarding how you are doing with the class facilitator(s), classmates, and SELF staff?*
What personal strengths, characteristics, or capabilities will you bring to the Microenterprise class?
From the following scale, with 1 being the lowest and 10 being the highest, how open are you to business coaching?*
Attendee Requirements

You are expected to attend all sessions. There are ten (10) sessions, including orientation and graduation. Each session meets from 6:00 P.M. until approximately 9:00 P.M. every Wednesday for 10 consecutive weeks. If you miss two (2) sessions, you will be denied graduation from the class and be asked to withdraw from the program without recourse. S.E.L.F. reserves the right to change the class dates and times, if required, for the success of the program. Some class sessions may be conducted virtually if deemed necessary.
Are you able to fulfill the required time commitment, including one on one business coaching?*

YesNoNot sure
A written business plan will be developed as part of the class participation, which may require additional time. Are you able to contribute more time to complete a business plan assignment?*

YesNoNot sure
I understand the purposes of S.E.L.F.'s Microenterprise Class. If I become a participant, will devote the time and energy necessary to make it a successful experience.
Signature

Clear
Signature Date

MonthDayYear
Date
Application deadline is the close of business on the date indicated in the letter of instructions. All pertinent information i eluding application must be enclosed for this application to be considered.
Should be Empty:

Microenterprise Class Participant Profile