SEWBC Client Form

New Client Form

Welcome to the Southeast Women's Business Center! Memebership is free, so just complete the form below to get started!

First Name

Middle Initial

Last Name

Name of Company
(if applicable)

Home Phone

Work Phone

Fax

Address1

Address2

City

State

County

Zip Code

Zip+4

Race

Native American or Alaskan Native
Asian American
Black or African American
Native Hawaiian or other Pacific Islander
White
I Do Not Wish to Respond

Ethnicity

Hispanic Origin
Not of Hispanic Origin
I Do Not Wish to Respond

Business Owner Gender

Male (50+%)
Female (50+%)
Male/Female (50%/50%)
I Do Not Wish to Respond

Do you consider yourself a person with a disability?

Yes No

Veteran Status

Veteran
Service Connected Disabled Veteran
Disabled Veteran
Non-veteran

How did you hear about our program?
(check all that apply)

Word of Mouth
Bank
Newspaper
Chamber of Commerce
Internet
Radio
Television
Magazine
SBA
Other (please specify)

Describe the nature of the counseling you are seeking

Business Plan
Buy/Sell a Business
Capital Sources
Financial
Franchise
Human Resources
International Trade
Marketing/Sales
Business Start-up
Technology
eCommerce
Other (please specify)

Currently in Business?
(If no, skip the business information section)

Yes No

Business Information

Is this a Home-based Business?

Yes No

Type of Business

Do you conduct business online?

Yes No

Business started on

Month (MM) Year (YYYY)

Indicate preferred date and time for appointment

Date (MM/DD/YYYY)

Time (HH:MM) AM PM

Would you be more likely to attend a program designed for women entrepreneurs than one for business persons in general?

Comments:

Thank you.