Date* Date Format: MM slash DD slash YYYY Section IName* First Last Email* Phone*Business Name*Business Phone*Business Type*Business Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Do you have a business license?*YesNoIn processYears in Business*What is your annual net revenue?*Is this your first/only business?*YesNoPercentage of Ownership:*Please enter a number from 1 to 100.Business Demographic*Woman-OwnedPartially Woman-OwnedVeteran OwnedEthnicityBlack or African AmericanWhiteAmerican Indian or Alaska NativeAsian IndianChineseJapaneseKoreanFilipinoVietnameseOther AsianNative HawaiianSamoanChamorroOther Pacific IslanderOtherPlease describe your business:*What type of services are you requesting? E-Commerce Websites Mobile Applications CRM Databases Online Customer Service Accounting Health & Safety Budget & Cash Flow Planning Service & Product Pricing Strategies Building Systems and Processes HR Support COVID-19 Business Requirements Guidance Hospitality Consulting Legal Consulting Other Please Describe Other Services:*Have you utilized the Center for Business & Innovation services before? If so, which ones?* STEADI PTAC SCALEUP WCWB Coaching BEST THINK SBDC I have not used any of these. Do you have a website currently?*YesNoWhat is your website URL?* Do you sell online now?*YesNoHow/Where do you sell online?*How often do you update your accounting system with expenses?* Daily Weekly Monthly Quarterly Semi-Annually Annually What do you use for an accounting system now?*NotebookExcelQuickbooks/MintDo you have a bookkeeper?*YesNoDo you use accounting reports to make decisions about your business?*YesNoIf you had access to these reports, would you utilize them?*YesNoDo you need support filing back taxes prior to 2019?*YesNoHas your business ever applied for a loan and been denied?*YesNoWhen was the last time you increased your business prices?*Do you have a current business plan?*YesNoDo you have an accident prevention plan for your business?*YesNoWould you like support with an accident prevention plan?*YesNoWould you like to learn more about LNI requirements for business owners in Washington State?*YesNoNumber of Full-Time Employees as of 01/01/2020*Number of Part-Time Employees as of 01/01/2020*Section IIHas your business been impacted by COVID-19?*YesNoPlease provide a brief explanation of what adverse economic effects the disaster has had on your business:*By what percent has your revenue declined during the COVID-19 pandemic?*Please enter a number from 1 to 100.Has you made layoffs due to COVID-19?*YesNoWere you able to receive COVID-19 relief funding through the Paycheck Protection Program?*YesNoWere you able to receive COVID-19 relief funding through the EIDL (Economic Injury Disaster Loan)?*YesNoHow will the services you are requested support your business in relation to the impacts due to COVID-19?*Is there anything you want your local City/State/Government to know about your economic impact or anything you like them to do to support your business during this time?*Is there a class you wish was available to you at no cost that would help grow your business and skills? Please explain.*How did you hear about us?*Signature* First Last Date Date Format: MM slash DD slash YYYY Debarment StatementBusiness owner certifies that by signing this agreement, they are not suspended or debarred from participation by any federal department or agency.