Intake Form - Entrepreneurship Center @CTI
Please complete the form below to request more information.
Contact Information
First Name
Last Name
Home Address
Home City
Home State
Home Zip Code
Cell Phone (xxx) xxx-xxxx
Email
Preferred Contact Method
Email
Phone
Location Type
Please select...
Suburban
Rural
Urban
Preferred Language
Birthday
Are you LGBTQ+
Yes
No
Prefer not to answer
Gender
Male
Female
Other
What is your Race?
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian and Other Pacific Islander
White
Other
Multi-race (two or more of the above)
What is your Ethnicity?
Hispanic, Latino or Spanish Origins
Not Hispanic, Latino or Spanish Origins
Do you describe yourself as an immigrant to the U.S.?
Yes
No
Are you a veteran?
Yes
No
How many people are in your household?
Business Information
Business Name
Your Title
Business Email
Business Street
Business City
Business State
Business Zip Code
County
Please select...
Middlesex
Essex
Norfolk
Barnstable
Hampshire
Franklin
Plymouth
Worcester
Berkshire
Suffolk
Bristol
Hampden
Dukes
York
Washington
Lincoln
Oxford
Penebscot
Hancock
Cumberland
Somerset
Kennebec
Business Phone
Business Start Date
Website Address(or intended if not purchased yet)
Business Entity/Type
Please select...
Limited Liability Company (LLC)
Sole Proprietorship
C-Corporation
S-Corporation
Partnership
Nonprofit
Haven't started yet
Other
Cooperative
Industry
Please select...
Agriculture
Apparel
Beauty & Personal Care
Biotechnology
Communications
Construction
Consulting
Education
Energy
Engineering
Entertainment
Environmental
Finance
Food & Beverage
Healthcare
Hospitality
Insurance
Manufacturing
Media
Not For Profit
Recreation
Retail
Shipping
Technology
Transportation
Utilities
Other
Business Facebook (or intended if not purchased yet)
Business Instagram (or intended if not purchased yet)
What Business Stage are you in?
Idea Phase (>1 year from starting a business)
Launch/Pre-Startup (>1 year)
Startup (Operating and generating some revenue)
Established (profitable and employing at least one FT person)
Do you have a completed business plan?
Yes
No
Do you have completed Cash Flow Projections?
Yes
No
How many employees do you have?
1 (You're a solopreneur)
2-5
5-20
20-40
40+
Is your business woman owned? (50% or more of the business is owned by a woman)
Yes
No
How much revenue did your business generate last year?
Pre-Revenue
$1-50K
$51-100K
$101-200K
$201-300k
$301-400k
$401-500k
$501-750k
$751-1M
over $1M
Choose the answer that best describes where you are in your journey
You're building the foundation of your business
You're no longer a rookie, but you still have a lot left to learn before you can reach your ultimate vision
You're passionate. You've already started growing your team. Now you're looking for that next step
You've accomplished everything you set out to do, and you're ready for new goals and new challenges
What ECenter programs are you interested in?
SBA Microloan
ECenter Business Coaching
Grant Opportunities
Other
Please explain business/business briefly
Other assistance
How did you hear about us?
Please tell us, in your words, how we can support you to achieve your business goals?
What motivated you to open this business?
Please explain what you feel you need the most help on
(Financials, Business Guidance, Marketing, Business plans and Cash Flow etc.)
Is this business your main source of income?
Yes
No
What is your vision for the business moving forward?
Do you have access to a computer and necessary skills to run a business? (Microsoft Office, Quickbooks, other etc.)
Please select...
Yes
No
Other
Other business equipment
Contact Information