Cares Program: Consulting Client Inquiry Form

Cares Program Consulting Client Inquiry Form
The WBEC-East Cares Program is a federally-funded SBA program that provides support to business addresses in Philadelphia, Bucks County, Montgomery County, Delaware County, Lehigh County and Chester County. If your business address is outside of these areas, locate and contact your local Small Business Development Center or Women’s Business Center for COVID-19 related resources. If you have any trouble contacting your local business centers, please do not hesitate to contact WBEC-East with your questions or concerns. Please feel free to view our upcoming webinars, available to all businesses.

To ensure we match you with the most appropriate resource, we need to collect some information. All information you give us will be kept strictly confidential. We never report personal or business information by individual or business name.

Our SBA funding allows us to provide these services at no cost to you, the business owner. In exchange for this financial benefit, please help us to continue to serve you by answering the questions below as completely and accurately as possible.

Thank you!
Contact information
Date *

Month Day Year
Date
Name

First Name Last Name
Email *
example@example.com
Phone Number *
xxx-xxx-xxxx
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number Type *
If you're in business, please provide your business address.
Website
www.wbeceast.com
How did you hear about this program? *
PLEASE READ & SIGN BEFORE CONTINUING WITH FORM

REQUEST FOR ASSISTANCE AND CERTIFICATION

I request business management counseling and/or training from the Women’s Business Enterprise Center East. I agree to cooperate should I be selected to participate in surveys designed to evaluate WBEC-East services. I further understand that any counselor or trainer in this program has agreed not to: (1) recommend goods or services from sources in which he/she has an interest and (2) accept fees or commissions developing from this counseling or training relationship. I waive all claims arising from this assistance against all personnel of WBEC-East, its parent or sponsoring organization, if any, and its host organizations, and other resource counselors.

I certify that all my statements contained on this form are correct to the best of my knowledge and that I will cooperate in providing follow up information needed to evaluate the effectiveness of the program if asked by an authorized representative of the Women’s Business Enterprise Center East.
Signature *
Please describe the specific support you're requesting (financial; marketing; HR; executive coaching, etc) *
Please answer the following demographic questions. Your information will be kept confidential.
1. Date of Birth *

Month Day Year
2. Are you:

Female Male Other Prefer not to answer
3. Ethnicity

Hispanic or Latino Not Hispanic or Latino Prefer not to answer
4. Race

Asian Native American/Alaska Native White Black or African-American Native Hawaiian/Pacific Islander Prefer not to answer
5. Do you consider yourself to be a person with disability? *

Yes No Prefer not to answer
6. Do you receive:

State welfare (e.g., General Assistance) Federal welfare Unemployment (UI) Food stamps
7. Veteran status *

No Military, Reserve or National Guard service Veteran Service-Disabled Veteran Member of the National Guard Member of the Reserve Active Duty Spouse of Military Member Prefer not to answer
8. Please tell us your current employment status (check all that apply) *

Self employed full-time (35 hours or more a week) Self employed part-time (fewer than 35 hours a week) Employed for someone else full-time Employed by someone else part-time Unemployed less than 6 months Unemployed 6 months or more Currently looking for work Retired/other
9. How has COVID-19 impacted your business? *

Reduced staff hours Reduced number of staff Reduced hours of operation Transitioned to remote operations Suspended operations Increased business debt Canceled contracts / orders Pivoted to new product / service
10. How important is it to you that this program targets women? *

Very Important Somewhat Important Not Important
In question 11, and in other questions, we'll ask you about your business now and in the future to help us to understand the impact of our efforts on the economy. All information will be kept confidential and you may elect not to respond.
11. Which of the following most closely resembles your current stage of business development? *

A. Thinking about starting a business B. Am in process of starting a business but have made no sales C. Have opened a business and made sales within the last 12 months D. Have been in business with sales for more than 12 months
If you selected A or B above, you have completed the form. Please leave the remaining fields blank.

If you selected C or D, please complete the following questions about your business.
12. In what month and year did you open your business and make your first sale?
What's your business name?
13. What type of business are you in?

Agricultural, Forestry, Fishing & Hunting Construction Retail Trade Finance & Insurance Management of Companies & Enterprises Health Care & Social Assistance Other Services (except Public Administration) Mining Manufacturing Transportation & Warehousing Real Estate & Rental & Leasing Administrative & Support Arts, Entertainment & Recreation Public Administration Utilities Wholesale Trade Information Professional, Scientific & Technical Services Educational Services Accommodation & Food Services Waste Management & Remediation Services
14. Please describe your business, listing your main products and services, and your main types of customers (such as other businesses, governments, or individuals)
15. What percentage of your business is woman owned?
16. Is your business certified by any of the agencies listed?

Federal government 8(a) WBENC City of Philadelphia State of Pennsylvania Hubzone PennDOT SEPTA NMSDC NGLCC
17. Do you operate your business from home?

Yes No
18. Do you operate your business online?

Yes No
19. What is the legal structure of your business?

Sole Proprietorship Limited Liability Company (LLC) Partnership Subchapter S Corporation Corporation Non-Profit Corporation
20. For your most recent full business year, what was the largest number you had of full-time (more than 35 hours per week) and part time (fewer than 35 hours per week) employees — including yourself:
20. For your most recent full business year, what was the largest number you had of full time employees (more than 35 hours per week) including yourself?
For your most recent full business year, what was the largest number you had of part time employees (fewer than 35 hours per week) including yourself?
21. For your most recent full business year, what was your gross revenue/sales?
For your most recent full business year, what was your net profit or loss?
21. For your most recent full business year, what was your:
22. Does your business export to other countries?

Yes No
If yes, please list all the countries to which you export
If you do export to other countries, how many of your full time employees are engaged in the exporting aspect of your business?
If you do export to other countries, how many of your part time employees are engaged in the exporting aspect of your business?
For your most recent full business year, how much of your gross revenue/sales was related to exporting?
Should be Empty:

Cares Program Consulting Client Inquiry Form

Contact information