• Her+ Business Builder Enrollment

    October 13, 2026-December 15, 2026
  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • DOB:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Veteran:
  • Spouse of Veteran:
  • Format: (000) 000-0000.
  • Preferred Contact
  • US Citizen:

  • Tell Us About Your Business or Idea

  • Do you currently have a business or business idea?
  • What would you most like help with?
  • Ethnicity:
  • Race:
  • Marital Status:
  • Currently Employed:
  • If yes:
  • Single Parent:
  • Homeless:
  • Ex-Offender:
  • This form helps us confirm your eligibility for services in our program.

  • Eligibility Checklist

  • 1. Have you provided any unpaid household services for family members? (Examples: caregiving, childcare, cooking, cleaning, managing the home.)
  • 2. Do any of the following apply to you? (Mark any that apply)
  • 3. Have you had, or would have, difficulty getting a job or moving up in employment?
  • (If Yes, select any barriers that apply)
  • 4. Do any of the following apply to you today? (select the option that applies)
  • Reason support stopped if selected option above:
  • Date support ended:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • ABILITY TO WORK IN UNITED STATES

  • I attest that I am legally able to work in the United States (even if you are not currently working)
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  •  
  • Should be Empty: