PMBA HOME
Name
Address
City State ZIP
Telephone Cell Phone
Fax E-mail
What is your race/ethnicity?
Asian Black or African-American Hispanic Native American or Alaska Native
Native Hawaiian or other Pacific Islander White/Caucasian Other:
What is your gender?
Male Female
Additional demographics (please check all that apply):
Veteran Active Military Service Service-disabled Veteran Disability
Name of Company
Within which county is your business located?
Summit Medina Portage Other:
Within what boundaries do you offer your product/services?
Business description:
Legal entity of business/business organization:
C-Corporation S-Corporation Non-profit Corporation Limited Liability Corporation
Limited Liability Partnership General Partnership Limited Partnership Sole Partnership
Foreign Other
Type of business:
What specific product or service do you offer?
What percent of the business do you own? %
Describe your current marketing strategy:
Online Web sites:
Word-of-mouth
Flyers/Brochures List:
Yellow Pages
Newspapers List:
Magazines List:
Radio/Television Ads List:
Other List:
Is your business home-based? YES NO
To what organizations/associations (e.g., local Chamber of Commerce) do you/does your business belong?
Is your business Part-time Full-time?
Date business was started: month January February March April May June July August September October November December year
Business status:
Existing but declining Existing and healthy Starting Other
Total number of employees: full-time part-time
For the most recent full-business year, what were your:
a.) Gross Revenues/Sales: $
b.) +Profits/-Losses: $
c.) Current Business Assets: $
(Financial statements for the above mentioned data are required for program consideration. Please e-mail a copy to PMBA at aulmbdc@aol.com.)
Do you have a current business plan? YES NO If yes, e-mail a copy to PMBA at aulmbdc@aol.com.
In general, within the next two years, do you want to:
Increase number of employees by employees
Increase revenues/sales by $ /year
Increase business (Locally) within communities
Increase business (Regionally) within counties
Increase your business (State-wide)
Increase business (Multi-state level) states
Increase business (Nationally)
Increase business (Globally) within countries
Increase products/services list:
What services/assistance do you feel would help your business grow?
Comments/Justification for participation:
How did you hear about the PMBA program?
