Kelley Center Intake Form Kelley Center Intake Form Today's Date * Name * Name First First Last Last Preferred Method of Contact * PhoneEmailMail Email * Phone * Mailing Address Line 1 * Line 2 City * State * AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code * Proposed Business Name What is your proposed business name? Proposed Business Location Line 1 Line 2 City * State * AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code What type of location is this? * Home Owned facility Rented facility Unknown at this time Other Business Information Please give a brief description of the business you would like to start or have started. * What stage is this business in? * Idea only In process of starting or acquiring a business Currently own business (< 1 yr) Currently own business (1-5 yrs) Currently own business (> 5 yrs) What steps have you taken on your own? (Select all that apply.) * Business license Tax ID LLC filings State/local permits & licenses Business banking Marketing materials None Other Form of Business * Sole Proprietorship C-Corporation S-Corporation Limited Liability Company Partnership Unknown at this time Type of Business * Retail Service Wholesale/Distribution Manufacturing Construction Representative/Franchise/Licensee E-commerce Non-profit Undecided Do you have a business plan? * Yes No Partial, needs work Financial Information What is your gross income or expected gross income generated by the business? * Income generated by my business will be: * My primary source of income Supplementary income Unknown at this time How many employees (excluding yourself) do you have or plan to have? * Current Employment Status * Part-time Full-time Self-employed (part-time) Self-employed (full-time) Unemployed Are you currently seeking financing or grants? * Yes No Maybe What is the expected funding percentage from financing/grants? * 100% 75% 50% 25% 0% How much do you plan to personally invest into starting this business or how much have you already personally invested? (Please specify.) * General Information If qualified, would you be interested in business incubation? * Yes No Maybe Why do you want to be a small business owner? * Have you researched the business to determine the types of risks that may be involved? No Yes If this is an existing business, what areas of concern do you have about your business? * Business planning Human resources Marketing Management Finance Accounting Business model Technology Other Please include any additional information you would like to share: * What type of services would you like to receive from the Kelley Center? * How did you hear about the Kelley Center? * I authorize emails concerning the client intake process. No Yes I authorize emails of general business interest from the Kelley Center. No Yes I understand that all information given and/or received is to be held to the strictest level of confidentiality. No Yes Demographic Information Race/Ethnicity * Asian Black/African American Native American/Alaskan Native Hispanic White/Caucasian Prefer not to answer Gender * Male Female Other Prefer not to answer Military Status * Active Duty Member of Reserve or National Guard Veteran Non-Veteran Not applicable Prefer not to answer Captcha Submit If you are human, leave this field blank.