Capital Readiness Program Intake Questionnaire

Capital Readiness Program Intake Questionnaire
Hello, Tell Us Who You Are.
Name*

First NameLast Name
Title*
Business Name*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Website
Phone Number*
Email*
Email for Newsletter
example@example.com
How Can We Help Your Growth?
Are you currently applying to one of our CRP Incubators, Accelerators and/or Financial Wellness programs?*

YesNo
Which CRP Program are you currently applying for?

BOWIE Business Innovation Center GovCon Growth Lab (Waitlist)CRP “Thriving Beyond Millions” Business Operations Accelerator (Waitlist)GovCon Financing – TBMODU Women’s Business Center Financial Wellness Incubator (Waitlist)Virginia Black Chamber Expanding Business Ecosystems (EBE) Accelerator (Waitlist)
Which CRP Program(s) are you interested in? Check all that apply.

LIVEPLAN Capital Readiness IncubatorNorfolk State University Innovation Incubator ProgramOld Dominion University Financial Wellness IncubatorUniversity of Maryland Global Campus Capital Readiness AcceleratorVirginia Black Chamber of Commerce Business Accelerator Program
Tell Us About Your Business.
Revenue Class*

Class 1 – Annual sales less than $1 millionClass 2 – Annual sales between $1 million and $10 millionClass 3 – Annual sales between $10 million and $50 millionClass 4 – Annual sales greater than $50 million
Industry*
Please list your NAICS Codes.
How long have you been in business?*

Less than a year1–3 years3–5 yearsMore than 5 years
Current number of employees?*
What is your current business formation?*

Sole ProprietorshipPartnershipLimited Liability Company or PartnershipS CorporationC CorporationNone of the above, pre-startupNone of the above, start-up
What is your primary Business Development Strategy?*

Direct SellingWord of MouthSocial MediaCorporate Supplier Diversity ProgramsGovernment ContractingOther (please specify below)
Are you NMSDC Certified?*

YesNo
MBE certification is the process by which the minority ownership status of a business is validated by the CRMSDC and its Certification Committee. The Committee determines, pursuant to the policies of the NMSDC, whether the approved business is owned, operated and controlled by person(s) who is determined to be a minority group member. CRMSDC certification is in accordance with NMSDC guidelines.

Learn More About CRMSDC's MBE Services
Demographics
Gender Identity*
Please specify.*
Sexual Orientation*
Please specify.*
Race*
Please specify.*
Services Requested (check all that apply):*

Access to CapitalTraining and EducationInformation about Emerging MarketsGeneral - Add me to your distribution listOther
Select all the ways that you may qualify as a socially and economically disadvantaged individual (select all that apply):*

Membership in a group that has been subjected to racial or ethnic prejudice or cultural bias within American societyGenderRaceSexual OrientationReligionLimited English ProficiencyVeteran StatusDisabilityMembership in a federally or state-recognized Indian TribeResidence in a U.S. TerritoryResidence in a rural communityResidence in a region adversely affected by persistent poverty or inequalityResidence in a community undergoing economic transitions (including communities impacted by the shift towards a net-zero economy or deindustrialization)Membership in an underserved community**Residence in a Community Development Financial Institution (CDFI) Investment Area (as defined in 12 C.F.R. § 1805.201(b)(3)(ii))None of the above groupsOther
**Underserved communities are defined by Notice of Funding Opportunity MBDA-OBD-2023-2007775: Populations sharing a particular characteristic, as well as geographic communities, that have been systematically denied a full opportunity to participate in aspects of economic, social, and civic life because of, for example: race, color, religion, sex, sexual orientation, gender identity, disability, residence in a rural community; and persistent poverty. See 31 C.F.R. 35.27(g)(11)(ii). “Underserved communities” includes Black, Latino, and Indigenous and Native American persons, Asian Americans and Pacific Islanders, and other persons of color; members of religious minorities; lesbian, gay, bisexual, transgender, and queer (LGBTQ+) persons; persons with disabilities; persons who live in rural areas; and persons otherwise adversely affected by persistent poverty or inequality. (See 31 C.F.R. 35.27(g)
Are You Capital Ready?
Your 20-point credit readiness summary ensures that we are providing the best possible service & support to you. Please check all that apply to indicate the tools and resources you currently have in place:*

2 years of past personal taxes filedAccountant/CPA/BookkeeperAccounting Software (ie: QuickBooks, Xero, Other)Banking RelationshipBusiness Banking/Checking AccountBusiness Documents Organized (Necessary Articles, licenses, permits, contracts, certifications)Business InsuranceBusiness PlanCapability StatementDun & Bradstreet #Financial Statements (Balance Sheet, Income Statement, Cash Flow Statement)Knowledge of Financial Numbers (Profit margin, cash flow projections, etc)Knowledge of how much capital you will need this yearLegal Guidance/SupportLife InsurancePersonal Financial StatementPitch DeckStrong Paydex Business Credit Report/Score (80+)Strong Personal Credit History/Report/Score (650+)Not Applicable at this timeOther
As you forecast ahead, how much capital do you need to sustain, grow or expand business operations this year?*
Acknowledgement of Client Relationship

By submitting this form, you agree to (a) acknowledge the relationship with the CRP awardee (the service provider); (b) disclose to the awardee outcomes based on the service provided; and (c) provide documentary verification to the awardee and/or MBDA for outcomes resulting from services provided.
Neither MBDA nor the awardee guarantees any particular outcome based on services provided by the awardee or third-party service provider and is not liable for any outcomes or business decisions made by the client or associated parties.

Privacy Disclosure and Information Use

By submitting this form, you agree to allow the CRP Awardee and/or MBDA to share this document, information contained therein, and any supplementary material provided by you or your company on an as needed basis with other U.S. Government agencies to carry out appropriate due diligence and more effectively advocate for your interests. This information may also be used by MBDA and/or the CRP Awardee for the purpose of conducting evaluations, research, studies, and analysis consistent with the MBDA mission as stated in the MBDA Act. Demographic data will only be used in aggregated and anonymized formats. This form is considered business confidential and will not be shared with any other person or organization outside the U.S. Government unless MBDA is given permission to do so by your company. All business confidential information will be protected from disclosure to the extent permitted by law.

Certification

By submitting this form, I certify that all the information provided is true and correct to the best of my knowled
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Capital Readiness Program Intake Questionnaire

Hello, Tell Us Who You Are.

How Can We Help Your Growth?

Tell Us About Your Business.

Demographics

Are You Capital Ready?