Western Dairyland Business Center
REQUEST FOR COUNSELING / NEW CLIENT RECORD
We receive our funding from a variety of grants, including the Small Business Administration (SBA). Our continual funding depends on our ability to collect and report the following information. All information collected is reported anonymously.
Fields in
Yellow
are required.
First Name:
Last Name:
Position:
Select One
Owner
President
Partner
Employee
Manager
Associate
Business Phone:
Check to be excluded in WDBC Mailings
No Mailings
Business Name:
Business Fax:
Home Phone:
Mailing Address:
County:
Email:
City:
State:
Zip Code:
Do you own your own business?
Yes
No
Bus. Owner's Information
Disabled/Handicapped
Business Status:
Currently in Business
Home Business
Business Start Date
Do you have Health Insurance:
Yes
No
Gender
Male
Female
Type of Business:
Retail
Service
Manufacturing
Construction
Wholesale
Other
Employment Status:
Self-employed
Employed by someone else
Unemployed
Other
What is your highest eduction level achieved?
Less than high school (no diploma or GED)
High school diploma or GED
Some college/vocational school (no degree)
College/vocational school graduate - In what major:
Veteran Status:
Non-Veteran
Veteran
Vietnam Era Veteran
Gulf War Veteran
Disabled Veteran
Service-Connected Disability
Active Military
Business Organization:
Sole Proprietor
Partnership
Corporation
S-Corp
LLC
Undecided
Number of Employees
Race:
White
Native American
Asian
Black
Hawaiian or Pacific Islander
Hispanic:
Yes
Business Description: (Briefly describe your business.)
Indicate, briefly, the nature of the service and/or counseling you are seeking:
How did you hear about our program? (Check all that apply)
SBA
TV/Radio
Internet
Educational Institution
Chamber of Commerce
Business Owner
Newspaper
Local Econ-Dev Office
Bank
Magazine
Word of Mouth
Other Client
Other
Income Information
(optional)
Please estimate your total GROSS household income on last year's tax return: $
Please check any kind of public assistance you are receiving below (check all that apply):
Food Stamps
Housing Assistance
Dept of Human Services
SSI
SSDI
Badgercare
Client Release
Wisconsin Entrepreneur's Network (WEN) Agreement
By signing below, I authorize WDBC to input my information into the WEN network so I can access economic development professionals with expertise in angel investors, trademarks, patents, doing business with the government, etc. I understand that I may receive WEN surveys that will allow me to evaluate WEN services received.
I do not want my information entered into the WEN network.
Please Print your full name
Title
Date
02/22/2012
I have answered these questions completely and accurately to the best of my knowledge.
I agree: