Valley Community Development Small Business Intake Form
Disclosures: Valley Community Development
will follow strict rules to protect your confidentiality. The personal data collected below including name, street address, email address and any other personally identifiable information is protected by the Data Privacy Act. You will never be named in any reports. Your responses may be looked at individually by the funding source, or contractors hired by the funding source to collect and analyze data, your name or street address will not be reported. Income, city, state, zip code, family size, and other demographic data will be reported. Contractors of HUD/DHCD or any City/State agency are covered by the same Data Privacy Act requirements to protect your privacy and staff must demonstrate that they have systems in place to protect against data disclosure.
Contact Information
First Name
Last Name
Home Address
Home City
Home State
Home Zip Code
Email
Phone
Cell / Alternate Phone
Business Information
(If you do not have official business information, enter your personal information.)
Business Name
If you do not have a business name, please leave this field blank.
Business Address
Business City
Business State
Business Zip Code
Business Email
Business Phone Number
Other Owners of the Business
Is there another person who owns this business besides yourself?
Yes
No
Name(s) of additional business owner(s):
Email address(es) of additional business owner(s):
What type of small business do you own?
For example: restaurant, pet groomer, acupuncture
What stage of Business are you in?
Prospective Business Owner (about 1 year from starting a business)
Pre-Startup (within one year of startup)
Startup (business operating/generating revenue less than 1 year)
Established Business Clients (in business more than 1 year and generating income)
Do you have any employees?
Yes
No
If you are paying yourself, please count yourself as an employee.
How many employees do you have?
How many of your employees are full-time workers?
How many of your employees are part-time workers?
What business setup do you have?
Please select...
Business has brick-and-mortar location
Home-based business
Business has another arrangement
Are you working with any other small business consultants? If so, who?
What are the top 3 business goals that our Valley Community Development Small Business Consultants could help you with?
Demographic Information
Combined Household gross annual income:
Your gross annual income is required data needed to fund our Valley Community Development Small Business Program. Your data is only shared for reporting purposes and we prioritize our clients' confidentiality.
How many people live in your household?
Do you identify as LGBTQ+?
Yes
No
Chose not to respond
Gender
Male
Female
Other
Choose not to respond
Are you disabled?
Y
N
Choose not to respond
Are you a Veteran?
Yes
No
Choose not to respond
Select the race(s) with which you most closely identify
Arab
African American
Asian
Black/Caribbean
Latino/Latinx
Native American
Native Hawaiian or Pacific Islander
White
Multiracial
Other
Chose not to respond
In addition to the above, do you consider yourself Hispanic?
Hispanic
Non-Hispanic
Chose not to respond
Do you identify as an immigrant or non-native English speaker?
Yes, an immigrant
Yes, a non-native English speaker
No
Do you consider yourself a minority?
Yes
No
By typing my name below, I certify that the information contained herein is true, complete, and correct to the best of my knowledge and belief. I affirm that I am associated with the business or prospective business receiving technical assistance.
Ok
Name:
Date:
Please indicate which mailing lists you'd like to subscribe to:
Monthly Newsletter
Homeownership Program Information
Small Business Assistance Information
Affordable Housing News
How did you hear about us?
Please select...
Word of Mouth
Website
Facebook
Twitter
Instagram
LinkedIn
Flyer
Another organization
Other
Other
Small Business Client
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Contact Information