Business Intake Long Form

Initial Intake

Initial Intake Staff

Aru Sasikumar

Jamesetta Diggs

Fuad Salan

Christine Lukudu

Shoua Salas

Sohini Bag

Fadumo Mohamed

Denise Butler

Nelima Sitati Munene

Other

ACER Partners

Entrepreneur

Is your business registered with the Minnesota Secretary of State?

Yes

No

What is your business Employer Identification Number (EIN)

Have you participated in an ACER business training program?

Yes

No

Are you interested in participating in a business training program? If so which one?

NDC Plan It!

Entrepreneurship Trainings

CNA Training

For men 18 yrs and older; are you registered for the selective service?

Yes

No

First Name

Last Name

Date of Birth (Enter in MM/DD/YYYY format)

Home Street Address

Suite or Apartment Number

City

State

- Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces AmericasArmed Forces EuropeArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUnited States Minor Outlying IslandsUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code

Owner's Email

Phone Number

Gender

Female

Male

Non-binary

Choose not to respond

Other

If you selected "other" gender, please specify:

Pronouns

How many people are in your household?

What is your household's yearly income?

Less than $20,000

$20,000 - $44,999

$45,000 - $84,999

$85,000 - $139,999

$140,000 - $199,999

More than $200,000

What is your racial/ethnic heritage? (Check all that apply)

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

If you would like to specify your racial/ethnic heritage, please do so here:

Are you a veteran?

Yes

No

Choose not to respond

Are you a person with a disability?

Yes

No

Choose not to respond

Sexual Orientation

Outcome Reporting

Are you an ex-offender?

- Select -YesNoPrefer not to disclose

Constituent Info - Individuals

What is your business revenue?

- Select -0 - 50K50k - 100k100k - 250kOver 250k

What services are you looking for from ACER?

Website Design/Development

Business Planning

Accounting

Financial Planning

Brand Development

Marketing/PR

Human resources

Legal & Insurance

Access to funding

Name of Business

Business Street Address

Business Suite or Apartment Number

City

State

- Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces AmericasArmed Forces EuropeArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUnited States Minor Outlying IslandsUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code

Business Email

How many years have you been in business?

Business type or legal entity for the brand

Sole Proprietorship

Partnership (LP/LLP)

Corporation (C Corp/B Corp)

Corporation (S Corp)

Limited Liability Company (LLC)

Corporation (non-profit)

Not Applicable / Not Registered

What is the primary industry for your business?

Agriculture, Forestry, Fishing and Hunting

Mining

Utilities

Construction

Manufacturing

Whole Sale Trade

Retail Trade

Transportation and Warehousing

Information

Finance and Insurance

Real Estate Rental and Leasing

Professional, Scientific, and Technical Services

Management of Companies and Enterprises

Administrative and Support and Waste Management and Remediation Services

Educational Services

Health Care and Social Assistance

Arts, Entertainment, and Recreation

Accommodation and Food Services

Other Services (except Public Administration, e.g. Hair Salon, Nail Tech, Auto Repair)

Public Administration

Total number of employees (full & part-time)

Are you a home based business?

Yes

No

Do you conduct business online?

Yes

No

Education

1st Grade-11th Grade

High school diploma/equivalent (GED)

Associate degree/technical degree

Bachelor's degree

Graduate/professional degree

12th Grade, No diploma

Some College, not completed

How did you hear about ACER? Check all that apply.

ACER Client

ACER Employee

ACER Website

Other Website

Bank

Government

Organization

Social Media

Other

If you would like to specify which website, social media channel, or other way you heard about ACER, please do so here. Thank you!

Preferred Communication Method(s)

Phone

Email

Postal Mail

SMS

Fax

Preferred Language

English

Spanish

Somali

Swahili

Hmong

THE BELOW QUESTIONS ARE FOR ACER STAFF TO ANSWER INTERNALLY

Yes

No

How prepared are the client for getting services with us?

What consultant do you recommend to this client?

How many hours is the client looking to dedicate to the program?

What tier level is this client on?

Tier 1

Tier 2

Tier 3

Why did you pick this tier ranking for the client?

Submit