First Name Last Name Email LinkedIn URL (If doesn't apply, write N/A) Phone Number What is your highest level of education? —Please choose an option—Some High SchoolSome CollegeHigh School Graduate or EquivalentTrade or Vocational DegreeAssociate DegreeBachelor's DegreeGraduate of Professional DegreePrefer Not to Answer Ethnic Background African-AmericanHispanicAsianNative AmericanWhiteOther If indicated "Other", please specify: Additional Status I am a WomanI have disabilitiesI am a single parentNo additional status applies Are you a veteran? YesNo Company Information Please fill this section out to the best of your ability. If you do not own a company, please fill out your home address under company address. Company Name Street Address City State / Province / Region Postal / Zip Code Country Fein Position Annual Sales Volume Under $50k$50K to $100k$100k to $500k$500k to $1M$1M-5M$5M-$10M$10M+ How many employees does your firm currently have? 1-55-1010-100100+ How many 1099 Contractors do you have? Are you in a Union? If answer is YES please submit which Union you belong to. If this does not apply to you submit "NO" What is your family's health insurance coverage? Some family members insuredAll family members insuredNo family members insured What kind of health insurance do you have? PublicBusinessPrivateEmployerSpouse's employer Briefly describe the nature of your business. Which areas do you need assistance? Developing a business plan?Updating financial statements?Preparing your taxes?Legal assistance?Obtaining business insurance?Obtaining bonding?Getting into a union?Securing/obtaining capital to stabilize business?Securing/obtaining capital to grow businessObtaining business coaching?Need MBE/WEB certification?Technology assistance? (website/social media/etc..) Which of the following apply to you? (Choose as many as you like) Trying to decide if business ownership is right for me, or if my business idea is viable, through the development of a plan.Need assistance and/or capital to stabilize my existing business.Need assistance and/or capital to expand my existing business.Need technical assistance to expand my existing business.Need business coaching or mentoring to expand my existing business.Need MBE/WBE/DBE certification assistance.Other (specify) If you selected Other, please specify: List your current certifications (if any) What are your expectations of joining USMCA? What are your primary goals? By checkmarking the below statement, I agree that all the information in this application is true to the best of my knowledge. If selected to participate and join the USMCA, I authorize the ongoing sharing of information with USMCA, including this report and any future progress, attendance, and/or termination. I understand all information will be kept confidential and only used in a collective form.
