Amplifying Opportunity in Tompkins Application Form

Women of Color Entrepreneurs Fund

We’re excited about your interest in joining our program! This 10-month initiative provides $10,000 ($1,000 per month) in grant funding, personalized support, and resources to help you grow/maintain your business. Please complete this application to tell us more about you, your business, and your goals.
Name*

First NameLast Name
What are your pronouns?*

She/HerShe/TheyHe/HisHe/TheyThey/ThemZe/ZirsOther
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Home Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did your hear about this grant program?*

Amplify Equity's StaffAmplify Equity's Facebook PageFriend or FamilyBusiness Leaders of Colors (BLOC)Alternatives Credit UnionSmall Business Development Center (SBDC)Other
Please list the name of who referred you, if applicable.
Name of your business*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What year did you start this business?*
What type of business to you have? (Ex: Food, personal care, athletic, landscaping, etc.)*
What support do you need? (Check all that apply)

Streamlining business operationsIncreasing salesManaging finances (bookkeeping, P&L statements, etc.)Decreasing expensesUnderstanding how to hire employeesHelp getting or retaining customersMarketing on social mediaFinding money to start or grow your businessTime management tipsGaining confidence in running a businessBuilding personal creditManaging the stress of running a businessLearning boundaries in businessOther

Demographics
As a reminder, your demographics answers are 100% confidential, do not impact your ability to participate in our programming, and are only used for internal tracking and grant reporting purposes.
What is your veteran status? (Please select all that apply)

Armed Forces Service Medal VeteranDisabled VeteranRecently Separated VeteranOther Protected VeteranMilitary Spouse (Non-Veteran)No Military Service
In which age group do you belong?

18 to 24 years25 to 34 years35 to 44 years45 to 54 years55 to 64 years65+ years
Do you identify with Hispanic, Latina/Latino/Latinx, or Spanish origin? (Please select all that apply)*

Yes, DominicanYes, GuatemalanYes, MexicanYes, Puerto RicanYes, SalvadoranYes, VenezuelanNoPrefer not to sayOther
Which of the following do you identify with? (Please select all that apply)*

Asian or Asian American (origin may be Chinese, Filipino, Indian, Korean, Pakistani, Vietnamese, etc.)Black or African American (origin may be Ethiopian, Haitian, Jamaican, Nigerian, Somali, etc.)Indigenous American or Indigenous Alaskan (origin may be Aztec, Blackfeet Tribe, Mayan, Navajo Nation, etc.)Middle Eastern or North African or Arab American (origin may be Algerian, Egyptian, Iranian, Lebanese, Moroccan, Syrian, etc.)Native Hawaiian or Pacific Islander (origin may be Chamorro, Fijian, Marshallese, Samoan, Tongan, etc.)White or European American (origin may be English, German, Italian, Russian, etc.)Prefer not to sayNone of theseOther
Which gender identity do you identify with? (Please select all that apply)*

Gender FluidNon-Binary / Non-ConformingManTransgenderWomanUnsurePrefer not to sayOther
Do you identify as part of the LGBTQIA+ community?

YesNoUnsure / QuestioningPrefer not to say
Do you identify as a person with a disability?

YesNoPrefer not to say
Have you personally experienced incarceration (spent time in jail and/or prison)?

YesNoPrefer not to say
Have you personally been impacted by the justice system? (Please check all that apply)

Yes, charges pressed and droppedYes, probationYes, served a jail sentenceYes, served a prison sentenceNoNo, I have not personally, but a close family member has beenPrefer not to sayOther
Family / Household Size*
Please count yourself and every person who lives in the same household as you.
Household Income*
How much is the income of the entire household?

The following questions are for internal use only and help us design our programs and services to best support our community and our clients.*

	Yes	No	Unsure	N/A
Is your credit score above 650?
Do you own your home?
Do you own a car?
Do you have 1 month's worth of expenses in savings?
Do you have retirement accounts?
Are you actively saving for retirement?

Your Vision and Goals
What inspired you to start your business?*
What are your top three goals for your business in the next year?*
How would a $1,000 unrestricted grant given monthly for 10 months either help your business grow or provide support for your personal life?*
What is your vision for your business and/or personal life 5 years from now?*

Commitment and Participation
This program includes monthly workshops and mentoring, with 2-5 hours of participation per month. Will you be able to commit this time, and how could we help make it possible for you to participate?*
What challenges do you face in your business right now, and how do you think this program could help?*

Community, Impact, and Personal Wellness
How does your business make a positive impact for your community, family, or customers?*
What impact do you want your business to have either on your personal life or on the community?*
Running a business can be stressful. What kind of support (e.g., financial coaching, stress management tools, childcare) would help you thrive as an entrepreneur?*

Additional Information
Additional Information: Anything else you would like us to know about you or your business?
Please upload your latest tax returns, to include your business tax filing (Schedule C), if applicable.

**NOTE: If you do not have tax returns, please submit the application and contact lindsay@amplifyequity.com to discuss alternatives.
Cancelof

Certification

By submitting this application, I certify that the information provided in this application is accurate and complete to the best of my knowledge. I understand that my application will be reviewed by a review committee and I will be contacted by Amplify Equity within 10 business days regarding an approval, denial, or waitlist for my application into the grant program.
Should be Empty:

Women of Color Entrepreneurs Fund