iMPACT Legacy Catalyst Program Application
Business Information
Business Name
Business Website
Business Phone Number
Please enter a valid phone number.
Business Email
example@example.com
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Type
Sole Proprietorship
LLC
Corporation
Partnership
Not yet registered
Business Industry
Estimated Annual Revenue
Less than $10,000
$10,000 – $49,999
$50,000 – $99,999
$100,000+
How many employees or contractors do you have?
Personal Information
Name
First Name
Last Name
Email
example@example.com
Mobile Number
By entering your mobile number, you agree to receive recurring promotional text messages from the Shirley Poole Legacy Foundation related to programs, events, scholarships, and business training opportunities. Message & data rates may apply. Reply STOP to unsubscribe at any time. Consent is not a condition of program
Gender Identity
Male
Female
Non-binary
Prefer not to say
Other
Race/Ethnicity
Black or African American
Hispanic or Latino
White
Asian
Native American or Alaska Native
Native Hawaiian or Other Pacific Islander
Other
How did you hear about this program?
Eligibility Review
Are you 18 years of age or older?
Yes
No
Do you currently reside in the United States?
Yes
No
Why do you want to join the iMPACT Legacy Catalyst Program?
What is your biggest challenge as an entrepreneur right now?
Have you previously received business training or mentorship support from any nonprofit or business development program?
If yes, please list the program(s)
What are you looking to learn from this program?
Are you a first-generation entrepreneur?
Yes
No
Not sure
Is your household income less than 80% of the Area Median Income (AMI) for your region?
Yes
No
Unsure
Do you identify as a member of an underserved or underrepresented group (e.g., Black, Hispanic, Native American, LGBTQ+, formerly incarcerated, disabled)? Yes/No If Yes, please specify below.
As part of the application process, all applicants must provide proof of income for eligibility review. Please upload your two most recent federal tax returns (Form 1040, 1120, 1120-S, 1065, and 990, including all schedules) and business financial statements. Your financial information will be kept confidential and used solely for program eligibility and reporting purposes.
Upload Federal Tax Returns
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Business Financial Statements (if applicable)
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Acknowledgement & Submission
I understand that this is a 12-month program and requires consistent participation.
I certify that all the information provided is accurate to the best of my knowledge.
I understand that if I am accepted into the iMPACT Legacy Catalyst Program, I will receive an official acceptance email with next steps and program details.
Signature
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