Start Up Business Assessment Survey

Contact Information regarding You and Your business

First Name *

Last Name *

Company Name *

Work Phone *

Email Address *

Address 1 *

City *

State/Province *

Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Virgin Islands Vermont Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Puerto Rico Palau

Postal Code *

Although the fields below are not required, the more information you provide, the better able we will be to assist you. Please answer all questions to the best of your knowledge. Please note that all information you provide will be considered proprietary and confidential.

2. How did you hear about us?

Website
Word-of-Mouth (friends, colleagues, etc.)
Social Media
Referral (lawyer, CPA, banker, etc.)
Business Networking Event
Other

referred by: Name and Organization *

Other *

3. Why do you want to start a business?

4. How much funding will your business require to start (estimate)?

5. Describe your business idea and the types of products and/or services you will offer:

6. Do you have any collateral (real estate, inventory, equipment, vehicle, CDs, stock)? If Yes, please identify the type of collateral in the extra text field provided.

Yes
No

Comment *

7. When do you plan to start the business (month, year)?

8. Please estimate your first year sales?

9. How do you plan to finance the start-up of your business (please check all that apply)?

Savings
Bank Loan/Line of Credit
Home Equity Loan
Investors
Friends, relatives
I don't require financing at this time.
Other

Other *

10. If you require financing, what will the money be used for?

11. How much money do you have available to invest in the business?

12. What is your current occupation?

13. Marital Status

Single
Married

14. Do you have a current copy of your credit report? (if “Yes,” please bring it to your initial meeting)

Yes
No

15. What is your current credit score?

16. What is your current annual household income?

17. Which legal structure are you considering for the business (choose only one)?

Sole Proprietorship
Partnership
Corporation
Limited Liability Company (LLC)
Limited Partnership (LP)
Not sure/need advice

18. Have you registered the name of your business?

Yes
No

19. Do you currently have a draft of your business plan?

Yes
No

20. Have you filed for bankruptcy within the past ten years?

Yes
No

21. Is your business home-based?

Yes
No

22. Have you found a location for your business?

Yes
No

23. Have you ever worked, or are you currently working in this industry? If Yes, please state your amount of experience in the text field below.

Yes
No

Comment *

24. Do you have a CPA or accountant?

Yes
No

If yes, what is the name of your CPA or accountant? *

25. Do you have a lawyer?

Yes
No

If yes, what is the name of your lawyer? *

26. Have you ever started or owned a business before?

Yes
No