CommunityEnterprise™ Application

Please fill out this application completely. Acceptance is based on your eligibility, and not all applications will be accepted (see our www.cie-nw.org/eligibility for details). All information provided on this application is strictly confidential; however, the information you provide in this application may be aggregated to help our prospective funders and partners know who we serve.

First Name*

Last Name*

Home Phone Number*

Cell Phone Number*

Email*

example@example.com

Best way to reach me is:*

EmailHome PhoneCell PhoneOther

Street Address*

City*

County*

Zip Code*

Gender*

MaleFemaleNonbinaryPrefer not to answer

Date of Birth*

Date

Ethnicity or Race (check all that apply)*

Education*

High SchoolUndergraduateGraduate SchoolOther

Do you need special accommodations to participate? (For example, sign language, interpretation or translation services, wheelchair access, etc.)*

YesNo

If so, please describe here:*

First Generation Immigrant?*

YesNo

Which languages are you most comfortable speaking and reading?*

How many adults live in your household (including yourself)? *

How many children or dependents live in your household ? (Include extended family members, if any.)*

What is your estimated total annual household income (Include income from all sources and all people living in your household. You can estimate annual household income by starting with a recent or typical month and multiplying it by 12 months.)

Are you or is anyone in your immediate household receiving (check all that apply):*

CommunityEnterprise™ Application

ABOUT YOU

ABOUT YOUR BUSINESS IDEA

ABOUT YOUR BUSINESS