Thank you for your interest in ACER services for business owners! Please fill out this form about you and your business. 1 Start 2 Complete Initial Intake Initial Intake Staff Aru Sasikumar Jamesetta Diggs Ra'Essa As-Sidiq Rasheed Stephens Shoua Salas Sohini Bag Fadumo Mohamed Denise Butler Nelima Sitati Munene Other Select all the staff members involve during the activity (door knocking, tabling, etc.) Entrepreneur First Name * Last Name * Date of Birth (Enter in MM/DD/YYYY format) * MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year19251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025 Year Home Street Address * Suite or Apartment Number City * State * Zip Code * Owner's Email * Phone Number * Gender * - Select -FemaleMaleNon-binaryChoose not to respondOther If you selected "other" gender, please specify: Pronouns How many people are in your household? * What is your household's yearly income? * - Select -Less than $20,000$20,000 - $44,999$45,000 - $84,999$85,000 - $139,999$140,000 - $199,999More 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 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 * Zip Code * Business Email * Is your business registered with the Minnesota Secretary of State? * Yes No What is your business Employer Identification Number (EIN) How many years have you been in business? Business type or legal entity for the brand * - Select -Sole ProprietorshipPartnership (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? * - Select -Agriculture, Forestry, Fishing and HuntingMiningUtilitiesConstructionManufacturingWhole Sale TradeRetail TradeTransportation and WarehousingInformationFinance and InsuranceReal Estate Rental and LeasingProfessional, Scientific, and Technical ServicesManagement of Companies and EnterprisesAdministrative and Support and Waste Management and Remediation ServicesEducational ServicesHealth Care and Social AssistanceArts, Entertainment, and RecreationAccommodation and Food ServicesOther 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 * - Select -Less than high schoolHigh school diploma/equivalent (GED)Associate degree/technical degreeBachelor's degreeGraduate/professional degree 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! 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 Preferred Communication Method(s) Phone Email Postal Mail SMS Fax Preferred Language - None -EnglishSpanishSomaliSwahiliHmong For men 18 yrs and older; are you registered for the selective service? Yes No THE BELOW QUESTIONS ARE FOR ACER STAFF TO ANSWER INTERNALLY Yes No Select "Yes" as an acknowledgement of: The below questions are for ACER Staff to answer after client meeting for INTERNAL use only 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? - None -Tier 1Tier 2Tier 3 Why did you pick this tier ranking for the client? Submit
