Capital Region Women's Business Center:
Intake Form

Please complete the below intake form in order to schedule a meeting with our Women's Business Center Business Advisors. This form will take less than 10 minutes to complete.

*PLEASE NOTE THIS IS NOT A LOAN APPLICATION

Personal Information

First Name*

Last Name*

Email*

Mobile Phone Number*

Street Address (Home)*

City (Home)*

County (Home)

State (Home)*

Zip Code (Home)*

Demographic Information

The following information is being collected as an opportunity to provide you and your business/nonprofit with new resources (small business funding, services, and programs), and will not impact your ability to access any of Wacif's programs and services.

Gender*

Age Range*

Household Income 2023

Optional

Household Size 2023

Optional

Business Information

Business Name (If none enter, N/A)*

Select Your Business Industry*

If you don't have an industry yet, please select 'Not Applicable'.

Year Established*

Type "N/A" if the business has not been established

Is this an operating business?*

Yes

Business Website

Optional

City (Business)*

Type "N/A" if the business has not been established

County (Business)*

Select "N/A" if the business has not been established

State (Business)*

Select "N/A" if the business has not been established

Number of Full-Time Employees*

How many full-time employees, including yourself and contractors, does your company employ?

Number of Part-Time Employees*

How many part-time employees, including yourself and contractors, does your company employ?

Annual Revenue 2023

Write $0 if not applicable

Annual Revenue 2024

Write $0 if not applicable

Additional Information

How did you hear about Wacif?*

Is there any additional information that you would like to share with us? Please enter below.

Optional

By submitting this form, I attest that, to the best of my knowledge, all information in the above referenced form is accurate and complete.

Furthermore, by submitting this form I attest to my understanding that this form is not an application for any of Wacif’s loan products and there is no guarantee of outcomes provided as it relates to my engagement with its advisory services.

I agree to receive communications related to these business services from Wacif.*

Capital Region Women's Business Center:Intake Form

*PLEASE NOTE THIS IS NOT A LOAN APPLICATION

Personal Information

Demographic Information

Business Information

Additional Information

Attestation

Capital Region Women's Business Center:
Intake Form