Contact Information:
Full Name:
Title:
If you are the owner what percentage do you own?
Home Street Address:
City:
State:
County:
Zip:
Home Phone Number:
Client Ethnicity:
African American
Asian American
Caucasian
Hispanic American
Multi-Ethnic
Native American
Gender
Male
Female
Gross Monthly Household Incomes:
< $1000
$1000 - $1999
$2000 - $2999
$3000 - $3999
$4000 - $4999
$5000 +
Highest Level of Education Completed:
High School
Technical/Vocational
College
Post Graduate
Household Status
Own
Rent
Number In Household:
Born in the United States:
No
Yes
Company Information:
Company Legal Name:
Company "Doing Business As" Name:
Percentage owned by ethnic minorities:
Company Street Address:
City:
State:
County:
Zip:
Business Status
Start-Up
Existing Business
For Existing Business Only:
Total Annual Sales:
For Fiscal Year Ending:
Total Number of Employees:
Total Number of Minority Employees:
Main Business Phone Number:
Phone Ext.
no spaces (example 6123326332)
Direct Business Number:
Mobile / Cellular:
no spaces (example 6123326332)
Fax Number:
E-Mail Address:
Company Web Site Address:
Business Type:
Minority Company
Minority Individual
Native American Tribe & Council
Non-Profit
If Minority Company - What Type:
Proprietorship
Partnership
S Corporation
C Corporation
LLC or LLP
How did you hear about MEDA?
If a non-profit or government agency, which one?
Briefly describe the product(s) and/or services of the business:
Check all areas in which you are seeking assistance or information:Business Start-Up
Business Acquisition
Financial Assistance
Loan Packaging Assistance
Seminars & Training
Certification
Business Plan
Mentoring
Subcontracting & Procurement
Additional PTAC Assistance Requested
Other (Specify Needs)
