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User Registration Form Personal/contact information: Name: Address: County: Email: Phone Number:   SSN#: Gender: Male Female Ethnicity: Asian Black Hispanic Native American Native Hawaiian White Other Veteran Status: Not a veteran Veteran    Vietnam Era Vet    Disabled Vet.    Disabled Vietnam Vet.    Service Connected Disabled Vet    Disabled: Yes    No    Business information: Business Idea/Name: Are you currently in Business?:    Yes    No    Minority owned?: Yes No Woman owned?: Yes No Geographic Location: Urban    Suburban    Rural    Training goal: Business Start    Business Enhancement    Professional Improvement    Self-improvement    Others    Number of employees: Part-time: Full-time: Financial information Plan to apply for a loan?: Yes    No    Source of income: SSI    Employed/Self-employed    Unemployment    Family assistance    Pension/retirement    No Income    Others    Housing type: Rental    Own House    Public housing    Homeless    Household Size - Number of people living in your household including yourself: Single parent?: Yes    No    Head of Household?: Yes    No    Tution Assistance: Yes    No    Household income:     per month per year Other information: How did you hear about the class?:    WORK4WV SBDC ELS SCORE EXCEL VA Vocational Rehab Sign in the Yard Billboard Website Radio TV Newspaper Friend/Relative Word of Mouth Other Dealt with SBA as:    Borrower    Surety Bond    Applicant    Certificate of Competency    Home About Loans Downloads Incubator BIZA$SIST M. B. Kitchen Contact Reg Copyright © 2005 EyeamInc.com   The US Small Business Administration (SBA) Grant (Grant # SBAHQ-04-Y-0034) is funded by the SBA. SBA's funding is not an endorsement of any products, opinions, or services. All SBA funded programs are extended to the public on a nondiscriminatory basis.