Name
*
First Name
Last Name
Business Title
*
Official Company Name
*
Primary Telephone #
*
Country
(###)
###
####
Email
*
Business Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
What is the legal structure of your business?
*
Sole Proprietorship
Limited Liability Company (LLC)
"C" Corporation
"S" Corporation
"B" Corporation
Nonprofit
Other
Is your business 51% or more owned by a female Veteran and/or military spouse?
*
Yes
No
Military Assoication
What is/was the associated branch of service?
*
Air Force
Army
Coast Guard
Marines
Navy
Other
What is your current status (check all that apply)?
*
Note, Military dependents do not qualify for this specific program.
How many years did you or your spouse serve (Active Duty and Reserve combined)?
*
Less than 3 yrs.
3 to 5 years
5 to 7 years
7 to 10 years
10 to 15 years
15 to 20 years
20 to 25 years
25 to 30 years
More than 30 years
Demograhics
Age Range
*
Under 21
22-35
36-45
46-55
55-65
Over 65
Ethnicity
*
Hispanic Orgin
Non-Hispanic Orgin
Race
*
If mixed race, please select all that apply.
Business Assessment
Identify from the selections below, if your business was or is being impacted by one or more of these issues due to COVID 19, please check all those that apply.
*
What is your primary business industry?
*
Natural resources and mining
Construction
Manufacturing
Trade, transportation, and utilities
Information
Financial activities
Professional and business services
Education and health services
Leisure and hospitality
Other Services (except Public Administration)
Please select the top ten issues from the selection below that have directly impacted you due to COVID 19. These can be both personal and business issues.
*
Is your business your primary source of income?
*
Yes
No
Please identify what percentage of your revenues have been impacted due to COVID-19?
*
My business revenues have not been impacted
14% or less
15% - 20%
20% - 40%
40% - 60%
60% - 80%
80% - 100%
I'm unsure of the exact percentage of impact
Please identify the type of assistance you have applied for related to COVID-19? Check all those that apply.
*
Please identify to date, all the financial assistance you where able to secure related to COVID 19. You need not outline any specific amounts received.
*
Please share if you have pivoted or repositioned your business due to COVID 19 and experienced any of these potentially positive impacts listed below? Check all those apply.
*
Personal Health & Wellness Assessment
Please share what you perceive as your greatest strength?
*
Please share what you perceive as your greatest personal weakness?
*
Please share what you perceive as the greatest threat to your threat to your personal health and wellness? competitors, industry ytrends, etc.
*
Please share what you perceive as the best opportunities to improve your personal health and wellness?
*
Do you currently have a business mentor/coach?
*
Yes
No
If you answer yes to the previous questions, please identify your mentor/coach association.
*
N/A
VWEC
SCORE
Bunker Labs
Women Business Center
Veteran Business Outreach Center
Another Free Mentorship Program
Fee-based Mentor/Coaching Service
SELECT SESSION AVAILABILITY
*
Please select the days and times that you are available to attend the required technical assistance sessions. Note availability for required session may impact potential program selection. Please check all those apply.
All times are listed based on central standard time
