Epicenter's Online Intake Assistant
NOTE:
Starting December 16, 2022, our offices will be closed to give our staff time to rest, reflect and recharge during the holiday season. We will resume processing intake submissions when we return to the office on January 3, 2023.
This intake form will help our team gain a better understanding of you, your business, and your business needs. After you complete the questionnaire, Epicenter will connect you to resources that will help you meet your business goals.
Contact Information
First Name
Last Name
Email
Phone
Which of the following best describes you?
Please select...
Founder/business owner
Part-time entrepreneur with one/multiple side-hustles
Representative completing on behalf of a company/business
Other
Which of these best describes your venture?
Please select...
For-profit
I'm not sure yet
Non-profit (please see Momentum Nonprofit Partners)
(Please note that Epicenter supports
for-profit
ventures. For nonprofit resources, please stop this form and visit Momentum Nonprofit Partners to learn more about supports for nonprofits.
momentumnonprofitpartners.org
)
Epicenter is committed to making sure that the entrepreneurs we serve reflect the diversity of our city.
The following demographic questions will help us identify and build resources to reach entrepreneurs in historically underserved groups.
Demographic Information
With which gender do you most closely identify?
Please select...
Female
Male
Gender Fluid or Non-binary
Other
Which of the following best describes your ethnic origin? Please check any/all that apply
Asian
American Indian, Native American or Alaska Native
Black or African American
Hispanic, Latinx, or Spanish Origin
Middle Eastern or North African
Multiracial/Mixed Heritage
Native Hawaiian or Other Pacific Islander
White
Other
Decline to Share
Which best describes your age?
Please select...
Under 18 years old
18 to 24 years old
25 to 34 years old
35 to 44 years old
45 to 54 years old
55 to 64 years old
65 years old or more
Decline to Share
Which describes your highest completed level of education?
Please select...
Some high school
High school diploma
Some college/university
Associate's degree
Bachelor's degree
Master's degree
Professional degree (e.g. MD, JD, etc.)
Doctorate degree (e.g. PhD, EdD, etc.)
Decline to Share
Household Income
Please select...
$25,000 or less
$25,000 - $49,999
$50,000 - $74,999
$75,000 - $99,999
$100,000 or more
Decline to Share
Are you a veteran?
Please select...
Yes
No
Decline to Share
Do you identify as someone with a cognitive, emotional, and/or physical disability?
Please select...
Yes
No
Unsure
Decline to Share
Do you consider yourself to be an LGBTQ+ entrepreneur?
Please select...
Yes
No
Decline to Share
Which languages do you speak and/or conduct business in? Check all that apply
English
Arabic
French
Hindi or Urdu
Mandarin
Spanish
Tagalog
Vietnamese
Other
Decline to Share
Do you reside in Shelby County? If so, in which neighborhood do you reside?
Please select...
Downtown
Uptown/Harbortown
South Bluffs
North Memphis
Frayser
South Memphis
Raleigh
East Memphis
Midtown/Cooper-Young
Orange Mound
Germantown
Hickory Hill
Bartlett
Cordova
White Haven
No, I live in a different area
Other
Business Details
Enter the name of your company or business idea
How would you best describe the products or services offered by your business? (250 character max)
Does your business have a physical address?
(If so please enter details below)
Please select...
Yes - My business has a physical address
No - My business does not have an address, but it will in the future
No - My business does not have an address, and/or business is conducted online only
Street Address
City
State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Zip/Postal Code
Does your company have a website? If so, enter it here. (If not, please leave blank)
Which best describes the structure of your business?
Please select...
Unincorporated/Sole Proprietor
LLC
C-Corp
S-Corp
Partnership
Other
How many years have you been in business?
Please select...
Less than 1 year
1-3 years
4-6 years
7-10 years
11 years or more
Which industry best describes your business?
Please select...
Advertising, Marketing, & Print Media
Agriculture
Airlines & Aerospace
Arts, Crafts, Small Batch Production, and Makers
Automotive
Construction, Machinery, and Homes
Consulting, Business Services, or Professional Services
Creative, Film, and Music
Emerging Technology
Family, Community & Civic Organizations
Finance & Financial Services
Government & Education
Hair Salons, Barbers, Nail Salons, Spas
Healthcare & Pharmaceutical
Hospitality
Information Technology & Telecommunications
Manufacturing
Medical Devices
Other
Real Estate
Restaurants, Foods, and Beverages
Retail - Online or Brick & Mortar
Transportation, Distribution, and Logistics
Utilities
Which best describes your revenue model? Check all that apply
Business to Business (B2B): Sells products/services to other
businesses
Business to Consumer (B2C): Sells products/services directly to customers
Business to Government (B2G): Sells products/services to government entities
Other Revenue Model
How many people does your business employ?
Please select...
No employees beyond founders or owners
1 - 5 employees
5 - 10 employees
11 - 20 employees
21 - 50 employees
51 - 100 employees
More than 100 employees
Which stage best describes your venture?
Please select...
Idea Stage: It's an idea right now
Pre-Revenue: It's open and/or developed! I am just waiting on my first customers
Revenue: It's open and currently making revenue, but it's not breaking even yet
Profit: The business is profitable (the revenue is larger than the expenses)
Expansion: Sustained profitability. Ready to begin growth, scaling, and/or acquisitions of other businesses
Closed/Out of Business
Which best describes your annual revenue (before taxes)?
Please select...
Under $10,000
$10,000-$24,999
$25,000 - $49,000
$50,000 - $74,999
$75,000 - $99,999
$100,000 - $149,999
$150,000 - $199,999
$200,000 - $499,999
$500,000 - $1M
$1M - $3M
$3M - $5M
$5M - $10M
$10M - $20M
$20M or more
Is your product or service currently available for purchase or for investment?
Please select...
Yes, it is currently available
Almost, it's currently being developed
No, my product or service is still an idea
Have you narrowed down/identified your specific target customer market?
Please select...
Yes, I have a clear understanding of who my customers are
I have a general idea of who my customers are, but I could refine it further
No, I have not yet narrowed my target customer market
Have you successfully raised funds or acquired capital for a business venture? If so what types? Check all that apply
Angel Funding
Venture Capital/Equity Based Funding
Loans/Debt Based Capital
Grant based funding
Directly Funded by owners/personal networks
COVID 19 emergency relief funding
None of these, but I plan to in the future
I do not plan to raise investment money for my business
Do you plan to scale or grow your business by adding new products or services, by expanding into new markets (locally/nationally/globally), by opening additional locations, or by using some other growth strategy?
Please select...
Yes - My business is currently growing, or has plans to grow beyond its current size
No - I intend to keep my business local and/or sustainably small
Maybe - I am not sure yet
In which of the following areas does your business need the most support?
I need help getting my business Started
Capital - Investors or Equity Financing
Capital - Banking, Lending, or Other Funding
Access to business mentor/mentorship
Access to social capital/personal connections
Finding or Identifying Customers
Pricing/Cost Structuring for my products or services
Building a website for my business
Business Finances
Business Pitch Support
Crisis Response
Human Resources/Staffing
Legal
Marketing/Sales
Product Development/Manufacturing
Commercial Real Estate
Other
Capital Needs
Are you currently seeking capital to help your business grow, or to fund the expansion of your company?
Yes
No
If your company is seeking capital, please complete the section below. If your company is NOT seeking capital, you may omit this section and proceed to the submit button.
What types of capital are you looking to raise/acquire? Check all that apply
Angel Funding
Venture Capital/Equity Based Funding
Loans/Debt Based Capital
Grant based funding
COVID 19 emergency relief grants, loans, or other types of relief funding
None of these
How much capital are you looking for?
Please select...
Under $10,000
$10,000-$24,999
$25,000 - $49,000
$50,000 - $74,999
$75,000 - $99,999
$100,000 - $149,999
$150,000 - $199,999
$200,000 - $499,999
$500,000 - $1M
$1M - $3M
$3M - $5M
$5M - $10M
$10M - $20M
$20M or more
How soon do you need this capital?
Please select...
1 - 3 months
3 - 6 months
6 - 9 months
9 - 12 months
More than 1 year from now
How do you plan to use the capital you seek?
Equipment
Real Estate
Facility Improvements
Inventory/Materials
New employee compensation
Existing employee compensation
Technology
Emergency/Unforeseen Circumstances
General start-up capital
General working capital
Since
you are looking for capital, we'd like to understand the documentation you have available. Please select the documents you already have for your business. Check all that apply
Personal financial statement
36 month financial projections
Past 2 years personal tax returns
Past 2 years business tax returns
Year-to-date balance sheet
Year-to-date profit & loss statement
Business Plan
Description of available collateral (for purpose of securing loan)
I have a business bank/business banking relationship
I have a relationship with a financial advisor
I could use some assistance getting my business finances/financial documentation in order
None of These/Not Applicable
Contact Information
Your Rights Under GDPR