HHWP Community Action Commission

Small Business Program Application

Name: First______________________________ M.I.______ Last______________________________

Address:________________________________________ City:___________________ Zip:_________

County of Residence: ___ Hancock ___ Hardin ___ Putnam ___Wyandot _______________Other

Phone: ________________Mobile Phone:_______________ E-mail: ____________________________

S.S. # _____-___-_____ Household size: _______ # of Adults:___ # of Children under 18:__

Education: ___ High School Graduate ___ College Graduate ___ Technical - Business School Graduate

How did you hear about our program? ____________________________________________________

Household Income Documentation for Program Eligibility

Documentation method: Income Source #1: ____________________________ $________

___Pay Stubs (last 3 months) Income Source #2: ____________________________ $________

___Federal Tax Return Income Source #3: ____________________________ $________

Total last12 months Household Income: $________

Business Information

Have you ever owned a business? Y N. If yes, please describe the business ___________________

____________________________________________________________________________________

Describe the business you own or would like to buy or start _______________________________

____________________________________________________________________________________

____________________________________________________________________________________

Why do you want to operate your own business?_____________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

I need training in these areas (check all that apply):

 All Areas Listed	 Deciding on a Business	 Creating a Business Plan
 Computer and Communication Tools	 Business Organization & Legal structure	 Business Licenses and Permits
 Insurance	 Location and Leasing	 Accounting and Cash Flow
 Financing my Business	 E-Commerce	 Buying a Business of Franchise
 Opening and Marketing my Business	 Expanding and Handling Problems	 International Trade
 ______________________	 ______________________	 ______________________

This agency does not discriminate because of race, color, age, sex, handicap, political affiliation or national origin in its employment and operational practices. If you feel you have been discriminated against, contact the Affirmative Action Officer at 419-423-3755 or 800-423-4304.

To the best of my knowledge, the information on this application is true and accurate. I understand that it is subject to verification and any misleading or materially inaccurate statement may render my application void. I also grant permission for the HHWP Community Action Commission (HHWPCAC) Microenterprise Manager or HHWPCAC principals to communicate directly and share information about me with other service providers as may be deemed necessary to best serve my needs and interests. This authorization shall remain in effect for a period of three years from the date of this application unless canceled, at any time, by written notice.

Applicant’s Signature: _______________________________________________ Date:____________________________