Impact AZ Program
Cohort 4 Participant Application
Welcome to a transformative chapter in your entrepreneurial journey!
Impact AZ is your gateway to empowerment, designed to elevate Arizona’s Minority-Owned businesses through enriched access to capital, tailored mentorship, and an inspiring community network. Ready to scale your business and achieve lasting success? Dedicate the next 10 minutes to complete this form—your first step toward actionable growth and impact.
1. Personal Information
Name
*
First Name
Last Name
Email
*
example@example.com
Sex
*
Female
Male
Other
City, State
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
2. Demographic Profile
What is your ethnicity?
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
Prefer not to answer
Other
What categories do you identify with? (select all that applies)
*
Persons with Disabilities
Veterans
LGBTQ+ Individuals
Justice Impacted
None
Other
What is your approximate annual income? (from your business and other sources if applicable)
*
Less than $100,000
$100,000- $250,000
$250,000- $500,000
$500,000- $1million
$1million - $5million
Back
Next
3. Business Information
Business Name
*
Type of business
*
Business Website URL
*
website, Instagram, etc
Length of Operation
*
Less than 1 year
1 to 3 years
3 to 7 years
more than 7 years
Business Stage Description
*
Start-up stage: Recently launched
Growth stage: Expanding market presence
Profit Stability: Seeing stable year-on-year profits
Expansion stage: Entering new markets/product testing
Is your Business registered with the Secretary of State, Arizona?
*
Yes
No
How many employees do you currently have?
*
It's only me
2-5
6-10
11-25
26+
Business Operation Plan: If you are a sole proprietor or have a small team (2–5 employees), do you have a strategy to manage your business while participating in the program?
Yes
No
If not, would you like assistance in developing such a plan?
Yes
No
Minority Business Certification
*
Yes
No
If Yes, what certification(s) do you hold?
Business Legal Structure
*
LLC
S-Corp
B-Corp
C-Corp
501(c)(3) Nonprofit
Other
Corporate/Government Business Engagements: Are you currently doing business with government entities or corporations? If so, please provide details.
*
Capability Statement
*
Yes
No
If yes, upload your capability statement.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Business Plan
*
Yes
No
If yes, upload your business plan.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Next
4. Program Commitment
Program Commencement Acknowledgement: The program officially begins on July 14, 2026. The Kick-off event is scheduled to be held in-person, during business hours (e.g., 9:00am - 12:00noon). Can you confirm your ability to attend the Kick-off event?
*
Yes
No
Weekly Commitment Confirmation: Participation in the program requires a dedication of at least 6 hours weekly (courses are generally 5:30pm - 7:30pm Phoenix time). Approximately 30% of the courses will be in-person. Are you able to meet this requirement?
*
Yes
No
Prior Accelerator Participation Inquiry: Have you taken part in any business accelerators or incubators before this application?bators?
*
Yes
No
Previous Experience Description: If you answered 'Yes' to the previous question, could you please share your experiences and key takeaways from those programs?
Back
Next
5. Financial Considerations
Scholarship Requirement Indication: Limited scholarships are offered for this program. If you are not selected for a scholarship, the fee to participate is $2,500. Do you need to apply for a scholarship to join the program?
*
Yes
No
The final step is a non-refundable application fee for processing and administration
Signature
My Products
prev
next
( X )
Impact AZ 2025 Application Fee
Application Fee
$
99.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
Should be Empty: