The CEI Women’s Business Center Advising Intake

Referrals

Have you already been in contact with, or scheduled a meeting with, a WBC or CEI Advisor?

Yes
No

WBC or CEI Advisor Contact

Please select which CEI Advisor you have previously or are currently working with.

Were you referred to us by MTI?*

Yes
No

Contact Information

Name*

First Last

Phone*

Email*

Address (Home)*

Street Address Address Line 2 City State ZIP Code

Business Status

Business Status*

We define "in business" as having some online or physical business presence, and already having had paid sales.

In Business
Not in Business

Business Information/Advising Need

Business Description*

Please write a brief description of type and stage of business or business idea.

Business name

(Leave blank if none)

Position/title in business

e.g. owner/manager/etc. (leave blank if none)

Website

Business Advising Need*

Please describe what you are hoping to achieve through advising at the CEI Women's Business Center. This might include specific issues you are facing, goals you are working towards, questions you have, etc. If you are filling out this form specifically to request credit counseling, please note that here.

Demographic Information

In order to keep our funders happy and our advising free, we are required to ask this information. We keep all information confidential, and report it only in aggregate.

Race*

Asian
Black
Native American
Hawaiian/Pacific Islander
White (Includes Hispanic)
Prefer Not to Answer

Ethnicity*

Hispanic
Not Hispanic
Prefer Not to Answer

Disability*

Yes
No
Prefer Not to Answer

Gender*

Military Status*

Veteran
Non-Veteran
Prefer Not to Answer

Business Data

In order to keep our funders happy, and our advising free, we are required to ask this information. We keep all information confidential, and report it only in aggregate.

Full Time Employees

For the purposes of this form we consider you, as the owner, an employee of the business.

Part Time Employees

For the purposes of this form we consider you, as the owner, an employee of the business

Annual Sales

Annual Profit/Loss

Business Legal Entity

Sole Proprietor / DBA
LLC
S-corp
C-corp

Percent of Female Ownership

0 to 100%

Please enter a number from 0 to 100.

Business Start Date

Confirmation and Signature

Would you like to be added to the WBC or CEI email newsletter?*

We periodically send out announcements about upcoming events, client success stories, and other important happenings.

Yes, both the Women's Business Center and CEI Newsletters
Yes, but the Women's Business Center newsletter only
Yes, but the CEI newsletter only
No, thank you

Electronic signature*

By typing my name below, I am electronically signing my request for advising and certifying that I have read and agree to the following: I understand that any information disclosed will be held in strict confidence. (SBA will not provide your personal information to commercial entities.) I authorize SBA to furnish relevant information to the assigned management advisor(s). I further understand that the advisor(s) agrees not to: 1) recommend goods or services from sources in which he/she has an interest, and 2) accept fees or commissions developing from this counseling relationship. In consideration of the advisor(s) furnishing management or technical assistance, I waive all claims against SBA personnel, and that of its Resource Partners and host organizations, arising from this assistance. I self-certify that neither I nor my company are currently in suspension or debarment by a Federal Agency.

Today's Date*

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