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Intake Form

In HBC we are interest in give you the best advisory to grow your business. Don’t worry, your Information about your business will keep strictly confidential and is reported only in the aggregate unless prior approval is received from you.

Forms

"*" indicates required fields

Business information

Are you currently in business?*

Business Address*

Business City*

Business State*

Business zip Code*

Business county*

Company name*

EIN Number*

Date of start of business? (First sale)*

Legal Entity*

Business Type*

Business is not Registered*

What is english proficiency?**

What is spanish proficiency?*

Client information

Name*

First Last

Mailing Address*

City*

State*

Zip Code

Phone number*

Email*

Gender Identity

Date of birth

Disability?*

Race*

Ethnicity*

Military Service*

Do you identify as a?

Do you describe yourself as an immigrant to the U.S.?*

If yes, number of years in the U.S.

Country of Origin*

Do you identify as a?*

Education Level*

Other business information

Business location*

Income generated business is*

Number of owners*

Number of full time employees (Do not include owner)*

Number of part time employees (Do not include owner)*

Estimated annual revenue*

Website business

Social Media Facebook

Social Media Instagram

Social Media Linkedin

Designation Group/Status

How may we help you?

How do you prefer your business consulting/mentoring?*

Client confirmation*

I have provided the information above, and understand that it will be kept confidential and used for loan assistance/business counseling by the Women's Enterprise Development Center. And program staff to verify compliance with project goals. And used for statistics purposes by Empire State Development Corporation.

I agree

Consent*

I CONSENT to the use of my name and/or my likeness for the purpose of advertising or trade byNew York State Department of Economic Development (“DED”) or anyone authorized by thatDepartment to act on its behalf. “My likeness” includes a photograph, videotape recording, film orartistic rendering of me, a recording of my voice, and/or reproductions of any of these. I agree that theactual material involved, such as a photograph, negative, plate, videotape recording, film or audiorecording is and shall continue to be the property of the New York State Department of EconomicDevelopment.

I agree

Date*