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TA Request: Business Owner

Please complete this form as an initial intake for ACER's Technical Assistance program. On completion, an ACER team member will get back to you to follow up on next steps.

Business Owner Information

First Name

Last Name

Gender

Female

Male

Non-binary

Choose not to respond

Other

Pronouns

Date of Birth

Address

City

Postal Code

State/Province

Phone Number

Email

Ethnicity

African (Liberian)

African (Somali)

African (Nigerian)

African (Kenyan)

African

Native American/Alaskan Native

African-American

Asian (Hmong)

Asian (Vietnamese)

Asian

Native Hawaiian/Pacific Islander

Hispanic/Latinx

Caucasian

Prefer not to respond

Veteran

Yes

No

Choose not to respond

Disability

Yes

No

Choose not to respond

Are you 18 years or older?

Yes

No

Are you registered for selective service?

Yes

No

Are an ex-offender?

Yes

No

What is your preferred form of communication?

Business Information

Business Name

Business Website (If none, please mark as N/A)

Business Address

City 2

Postal Code 2

State/Province 2

How many years in Business?

Business Industry

Is your business registered?

Yes

No