First Name *

Last Name *

Your email *

Phone No *

Address *

Country *

State *

City *

Zip Code

Organization

What is your Corporate Structure?

A) For-Profit B) Non-Profit C) Foundation D) Sole Proprietor E) Other

What type of support would be most beneficial to you?

A) Business Vision and Goal Setting (i.e. business strategy) B) Financial Planning (i.e. income/expense analysis) C) Business Operations Planning (i.e. cut costs and increase efficiency) D) Fundraising (i.e. loans and grants) E) Financial Recapitalization (i.e. restructuring debt) F) All of the above G) N/A

What industry are you in?

How many weeks of operating reserves (i.e. cash on hand) do you have to sustain your business?

A) 0-1 WEEK B) 2-4 WEEKS C) 1-3 MONTHS D) 4-6 MONTHS E) 7-12+ MONTHS

If you applied for emergency relief funding, were you awarded funds?

A) No B) Yes C) N/A

Do you have a business plan and/or strategic plan?

A) No B) Yes

Did you see a year over year decline in gross receipts in 2020

A) Yes B) No C) N/A

If yes, what was the percent decline?

A) 0-5% B) 6-10% C) 11-15% D) 16-25% E) 26-50% F) 51-75% G) 76-100% H) N/A

Services, Products, Programs, etc.

A) I provide services B) I provide products C) I provide programs D) I provide services to other businesses E) I provide services to communities

Have you eliminated any full time positions since March 1st?

A) No B) Yes C) N/A

As of August 1st, how many employees do you have?

A) 1-2 B) 3-5 C) 6-10 D) 11-20 E) 21-50 F) 51+ G) 0

Have you had to reduce the number of hours worked by your full time staff since March 1st?

A) No B) Yes C) N/A

How many customers/clients/patients do you see monthly?

A) 1-20 B) 21-50 C) 51-100 D) 101-1000 E) 1001+

Have you applied for any emergency relief funding?

A) No B) Yes C) N/A

Have you ever received a grant?

A) No B) 1-5 Grants C) 6-10 Grants D) 11-20 Grants E) 21+ Grants

Do you have an HR manager, director and/or equivalent?

A) No B) Yes

Do you have Tax Identification Number?

A) Yes B) no C) I don't know

Have you worked with a consultant before?

A) No B) Yes

How many owners/leaders of the business or organization?

A) None B) 1 Person C) 2 D) 3-5 E) 6-10 F) 11 or more

How many years in business?

A) 1-2 years B) 3-5 years C) 6-10 years D) 11-15 E) 16+ years

Do you have updated technology? (Ex. computers, website, apps, software, database, etc.)

A) No B) Yes

Do you have an operations guide and/or manual?

A) No B) Yes

Have you received any COVID releif?

A) No B) Federal Only C) State Only D) Federal and State E) Other (Please list them in the notes area)

Are you registered as federal government contractor?

A) No B) Yes C) N/A

Do you have government certifications?

A) City B) State C) Federal D) International

Do you have an Executive Leadership Team, group or equivalent?

A) No B) Yes

Are you a private, public, non-profit or government entity?

A) Private B) Public C) Non-Profit D) Government Entity E) A mixture of structures

Do you have legal support?

A) No B) Yes C) N/A

Do you have current financials? Either/or 2020, 2019, 2018, 2017

A) No B) Yes

Do you have contingency plans (backup plans)?

A) No B) Yes C) N/A

Who does your accounting?

A) Yourself B) Your accountant C) Accounting department D) Outside accounting firm E) Other

Do you have a company Bio

A) No B) Yes

Do you have a current marketing plan?

A) No B) Yes

Do you have a Duns number? If so, please submit it in the notes area below.

A) No B) Yes C) N/A

Anything else you'd like to share with us?

A) Please submit additional comments in the notes area.

Notes