Form

iMPACT Legacy Catalyst Program Application
Business Information
Business Name
Business Website
Business Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Business Email
example@example.com
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Type

Sole ProprietorshipLLCCorporationPartnershipNot 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 NameLast 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 Format: (000) 000-0000.
Gender Identity

MaleFemaleNon-binaryPrefer not to sayOther
Race/Ethnicity

Black or African AmericanHispanic or LatinoWhiteAsianNative American or Alaska NativeNative Hawaiian or Other Pacific IslanderOther
How did you hear about this program?
Eligibility Review
Are you 18 years of age or older?

YesNo
Do you currently reside in the United States?

YesNo
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?

YesNoNot sure
Is your household income less than 80% of the Area Median Income (AMI) for your region?

YesNoUnsure
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

Cancelof
Business Financial Statements (if applicable)

Cancelof
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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iMPACT Legacy Catalyst Program Application

Business Information

Personal Information

Eligibility Review

Acknowledgement & Submission