WI-MBDA CLIENT INTAKE FORM
PLEASE NOTE: The services provided by Business Center to the client are subsidized through Federal appropriations. The information we are collecting below is only for reporting on what businesses we are serving. Your information is confidential, is not shared, and is protected under the fullest extent of the law.
Name of Business
*
What is your role in the company?
*
What is your title at the company?
What is your business legal structure?
*
Limited liability Company (LLC)
S corporation
C corporation
Limited Liability Partnership (LLP)
Sole Proprietor
Non profit (501c3)
What is your primary NAICS code?
*
If you dont know your code, please visit www.naics.com
What is your business website address or write NONE
*
What is your annual gross revenue?
*
How many employees do you have (not including yourself)?
*
If you are in need of business financing, how much are you looking to borrow?
*
PLEASE PUT 0 IF YOU ARE NOT IN NEED OF BUSINESS FINANCING
Do you currently have a surety bond in place for your business?
*
Yes
No
Not applicable
If you answered yes to having a surety bond in place, what is the value of your surety bond?
Date
*
-
Month
-
Day
Year
Date
Your name
*
First Name
Last Name
Client Signature
*
Continue
Continue
Should be Empty: