1.  NAME OF BUSINESS: 

2.  STREET ADDRESS:    SUITE: 

3.  CITY:    4.  STATE: 

5.  PRIMARY CONTACT

            NAME: 

            POSITION: 

            BUSINESS PHONE:

            CELL PHONE:    

            E-MAIL ADDRESS: 

6.  PRIMARY WEB ADDRESS: 

7.  TYPE OF BUSINESS:  Manufacturing Trade Services Retail Distribution Specialty Services Entertainment Production Public Events Public Relations Professional Services Technical & Scientific Select One

8.  FORM OF BUSINESS:  Select One Corporation Limited Liability Company General Partnership Limited Partnership Joint Venture Sole Proprietorship                        

9.  HAVE YOU STARTED ROUTINE BUSINESS ACTIVITIES?  (CHECK YES OR NO)

Yes    No

 10.  MONTH STARTED:  Select Month January February March April May June July August September October November December     YEAR: 

11.   NUMBER OF EMPLOYEES: 

 12.  NUMBER OF HOURS DEVOTED TO THIS BUSINESS PER WEEK: 

 13.  TOTAL REVENUE OVER THE PAST 12 MONTHS:  Select One Not Applicable less than $100,000 $100,000 to $250,000 $250,000 to $1,000,000 $1,000,000 to $5,000,000 over $5,000,000

14.  PROJECTED REVENUE FOR THE NEXT 12 MONTHS:  Select One Not Applicable less than $100,000 $100,000 to $250,000 $250,000 to $1,000,000 $1,000,000 to $5,000,000 over $5,000,000

 15.  DESCRIBE YOUR BUSINESS & YOUR MAJOR PRODUCTS AND/OR SERVICES (50 words or less):

16.  DESCRIBE WHERE YOU WANT THE BUSINESS TO BE IN 6 MONTHS TO ONE YEAR (25 words or less):

17.  CONSULTING SERVICE AREA OF INTEREST (check all that apply):