Never Run a Business to Make a Living

(* Denotes Required Fields)

Personal Information
First Name: *
Last Name: *
Your Title:
Address:
Address 2:
City: *
State: *
Zip: *
Primary Email: *
Work Phone:
Mobile Phone:
Home Phone:
Demographic Information
We request the information that follows to satisfy reporting requirements of our grant funders. Please help us better describe our impact and the communities we serve. (Your information will be used in aggregate totals only.)
What is your gender?:
The state of Connecticut defines low and moderate income as those with household income (AGI) below $112,600. Do you consider yourself to be part of this group?:	Yes No Prefer not to respond
Race:	Asian Black or African American White Native -- American or Alaskan Native Hawaiian or Pacific Islander Prefer not to respond
Ethnicity:
Do you consider yourself a person with a disability?:
Current military status:	Not in the military On Active Duty In the Reserve or National Guard Spouse of a member of the military Prefer not to respond
Military Veteran status:	Not a Veteran Veteran Service-disabled Veteran Spouse of a Veteran Prefer not to respond
Select one:	I am a current CEDF client I am a small business owner but not a CEDF client I am interested in small business education topics but not a business owner
About your Business
If you are not currently in business for yourself you may skip to the acknowledgement section below.
Date business started:
Business name:
Business Address:
Business Address 2:
City:
State:
Zip:
% of female ownership:
Exporting?:
Annual sales:
Form of organization:
Business industry:	Manufacturing Technology Construction Healthcare Retail Other
Jobs in your business: Include yourself, other owner(s), full-time and part-time employees and independent contractors. (Total people):
Acknowledgement
By typing my full name in the box below I agree that CEDF may use my information collected above for the stated purposes. Our organizations will send you future announcements of educational programs, for which you may opt out of at any time.
Signature:

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