Northeast Entrepreneur Fund
CUSTOMER INFORMATION SHEET
 
    1. Last Name
 		 2. First Name
 
    3. Mailing Address
 		 4. Street Address (if different than mailing address)
  
    5. City
 		 6. State
  		  7. Zip
  		  8. County
  
    9. Home Phone
 		 10. Cell Phone
  		  11. Home Email Address
  
    12. Race (select one)
      White
      Black/African American
      Asian
      American Indian/Alaskan
           Native
      Native Hawaiian/Other Pacific
           Islander
      Asian & White
      Black/African American &
           White
      Asian/Pacific Islander
      Hispanic
      Am. Indian/Alaskan Native &
           White
      Am. Indian/Alaskan Native &
           Black/African American
      Other Multi-Racial		 13. Ethnicity (select one)
     Hispanic or Latino
     Not Hispanic or
          Latino

14. Citizenship
      US Citizen
      Permanent, legal
           US resident
      Neither of the
           above

15. Do you consider yourself a person with a disability?
       Yes
       No

 16. Education
     Some High    School
     HS graduate or
          GED
        Vocational/Technical
     certificate
     Some college/AA
           degree
     Have BS/BA degree
     Advanced degree
     Other

17. Veteran Status
      Non-Veteran
      Veteran
      Disabled Veteran
      Service-Connected Disabled Veteran

 

 18. Age
      Under 20
      20-29
      30-39
      40-49
      50-59
      60 or over

19. Gender
      Male
      Female

20. Relationship
      Married
      Single
    21. How did you hear about the Northeast Entrepreneur Fund?
            Government Agency                                        Family/Friends                           Newspaper
             Another organization                                        TV/Radio                                   SBA
             Bank                                                              Brochure/Poster                         Other
             Entrepreneur Fund Customer                            Internet/Website
   

                                                                    FAMILY AND INCOME DATA

We base our hourly fees and scholarships on family income. We are required to report the income of our customers to our funders. If you elect not to provide this information, we may not be eligible for funder reimbursement for services we provide to you, nor will we be able to provide you with funder-subsidized fees or scholarships.

We may be required to verify your income for certain funding sources. Income verification can include a copy of your IRS Form 1040, W-2 statement, payroll stub, or verification through Minnesota Care, MFIP, W-2 TANF, USDA Food Stamp Program, Section 8 or Public Housing Program, Supplemental Social Security Income, or Workforce Center referral source.
 
    22. Family Size
        Adults
        Children		 23. Are you presently unemployed?
      Yes     No		 24. Are you the primary income earner in your family?
     Yes       No		 25. Did you qualify for the single parent head of household IRS deduction last year?
     Yes         No
    26. What is the present yearly total of your FAMILY income? (total income of everyone in your household, including yourself)

      $ 

 

 27. What is the current PRIMARY source of your FAMILY income? (check one)
 Self employed      Social Security/Disability  Rental
                                                                                                      Income

 Full-time job        Pension/Retirement            MFIP
 Part-time job       Alimony/Child Support        Other
 Interest/DividendsUnemployment Compensation
    28. What is the present yearly total of your PERSONAL income? (your individual income only)

      $ 

 

 29. What is the current PRIMARY source of your PERSONAL income? (check one)
 Self employed      Social Security/Disability        Rental
 Full-time job         Pension/Retirement                  Income      
 Part-time job        Alimony/Child Support            MFIP   
 Interest/Dividends Unemployment Compensation Other
    30. Did your income change recently, or do you expect it to change soon? If so, explain when, and why or how.

        No      Yes, date:   because

    31. How could you verify your income if asked to do so?
      IRS Form 1040         W-2          Payroll Stub     MFIP/Unemployment (Case number )
      Other (list)
     
   

BUSINESS DATA
    We are required to report to our funders certain data about the businesses with which we work. If you elect not to provide this information, we may not be eligible for funder reimbursement for services we provide to you, nor will we be able to provide you with funder-subsidized fees or scholarships.
 
    32. Business Status
Please indicate the status of the business you are planning to start, purchase or expand:
     Researching idea
     In business 6 months or less
     In business 6 months to 1 year
     In business 1 to 2 years
     In business more than 2 years		 33. Type of Business
Please indicate the primary purpose of the business you are planning to start, purchase or expand:
     Service
     Retail/Trade
     Manufacturing

34. Is this a home-based business?   Yes     No
    35. Please complete the following information (if known) about the business you are planning to start, purchase or expand:
   

Business Name:    

Business Phone:     
   

Business Street Address:    

Business Fax:          
   

Business City, State, Zip:    

Business Email:       
    Business County:    Business Website: 
    36. Please list all persons who are or will be involved in this business, including yourself:
    Name Phone Gender Relationship to Business
    Self Self Self Primary Owner   Partner  Shareholder      Other
    M F Primary Owner   Partner  Shareholder      Other
    M
 F		 Primary Owner   Partner  Shareholder      Other
    M
 F		 Primary Owner   Partner  Shareholder      Other
   

37. Is this business at least 50% women-owned?     Yes      No
   

38. Do you have a written business plan?
               No        Yes

39. Have you sought other assistance for your business?
               No        Yes
    40. Describe your business idea:
    41. What assistance would you like to receive from the Northeast Entrepreneur Fund? (Check all that apply)
            Business Planning                                              Operations/business management
             Cash management/financial reporting                   Personal/professional development
             Loan                                                                  Other 
             Marketing/sales/advertising/promotions
    The information you provide on this form is kept confidential. The Northeast Entrepreneur Fund does not discriminate in providing services to individuals on the basis of race, color, religion, sex, national origin, age, marital status, family status, or physical or mental disability. This information is used to report to our funders, many who require that we service specific populations. Without information about the people we serve, we would not meet our reporting criteria, and in some instances, may lose access to our funding sources.

Warning: Section 1001 of Title 18 of US Code makes it a criminal offense to make false statements or misrepresentations to any department or agency of the United States as to matters within its jurisdiction. Although Northeast Entrepreneur Fund is not a department or agency of the United States, we do receive funds from both federal and state sources.

   -- I certify that the information contained herein is accurate and complete
   -- I authorize Northeast Entrepreneur Fund, Inc. to verify the family and income information provided, as required by their funding sources.

  Signature:                  Today's date: 

 

 
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