Contact Information
Business Name
*
Client Information
Name
*
First Name
Last Name
Engagement Language
*
Please Select
Spanish
English
Stage
*
Prospect
Client
Business Status
*
In business
Pre-venture
Client Title
*
Partner
Manager
Key employee
Owner
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthdate
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Non-Binary
Decline to state
Intake form
Ethnic Origin, Ethnicity, or Race
Native American or Alaskan Native
Black or African American
Native Hawaiian
Other Pacific Islander
Asian
White/Caucasian
Hispanic or Latino/a
Other
Decline to
Marital Status
Single
Domestic Partnership
Married
Widowed
Do you consider yourself an Immigrant?
Yes
No
Do you have a Disability?
Yes
No
Are you the head of Household?
Yes
No
Household Size?
Number of children under 18 living in your Household
Military Status
Non-Military
Veteran
Service Disabled Veteran
Member Reserve or National Guard
On Active Duty
Annual Household Income
0 - 55
56 - 75
76 - 100
101 - 125
126 - 150
150 and up
Computer literacy Level
Beginner
Intermediate
Advance
How Did you hear about us?
*
Social Media(FB, IG)
Partner Referral
City of San Jose
Rotary Club
SBDC
LBFSV
CVIIC
SCCOED
Business Association
Word of Mouth
Business Walk
Business Advisor
Other
QR code or link provided by us
Lowest wage paid per hour.
What payments does the owner accept?
Cash
Credit / Debit cards
Bank transfers
Mobile payments and digital wallets.
Submit
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