First Name: *
Last Name: *
Name of Company: *
Please provide your title and responsibilities *
Business Address: *
City: *
State: *
Zip Code: *
Home Address: *
City: *
State: *
Zip Code: *
Cell Phone: *
Business Phone: *
Email: *
Business Website: *
Do you have a Philadelphia Issued Commercial Activity License? *
-Select One- Yes No
Please provide your Commercial Activity License Number Here *
Have you ever participated in any other Power Up Your Business Programs? *
-Select One- Yes No
Which program did you participate in? *
-Select One- Store Owner Series Peer Based Learning Industry Best Practices
If you participated in Peer Based Learning before, please indicate your former business name *
Please specify which series *
-Select One- Restaurant Best Practices Retail Bootcamp Import/Export Best Practices Home Healthcare Best Practices Barbershop/Salon Best Practices Childcare Best Practices Series Manufacturing Best Practices
Business Information
Minority-Owned: *
- Select - Yes No
Women-Owned: *
- Select - Yes No
Veteran Owned *
- Select - Yes No
Immigrant Owned *
- Select - Yes No
LGBTQ Owned *
- Select - Yes No
Ethnicity: *
- Select - Asian Black Hispanic/Latino Native American Indian, Indigenous peoples, or Alaska Native Native Hawaiian or Other Pacific Islander (NHOPI) White Multiracial (Individuals that identify as two or more races)
Is your business currently open and making sales? (Must be open for one year and making some sales to qualify) *
- Select - Business is open and making sales Business is open and not making sales I am not currently in business
If your business has been open, for how long? *
- Select - Less than a Year 1 Year 2-4 Years 5-7 Years 8+ Years
Do you know what commercial corridor your business is in? *
Do you work full time or part time on your business? *
- Select - Not at all Part-time (Less than 35 hours/week) Full-time (35 hours/week)
What were business sales last month? *
What was your reported revenue last year? *
- Select - Less than $29,999 $30,000 – $49,999 $50,000–$99,999 $100,000 –$ 499,999 $500,000 – $1,000,000
Are you able to pay yourself a salary from the business? *
- Select - Yes No
Do you have anyone else that you pay to help operate the business? *
- Select - Yes No
No. of Full-Time Employees (if applicable): *
No. of Part-Time Employees (if applicable): *
No. of Temporary paid employees (Independent contractors, 1099, etc.) *
Do you have a separate bank account for your business? *
Do you have inventory? *
- Select - Yes No
How much money have you put into the business? *
Have you ever applied for a business loan? *
- Select - Yes No
Name of Referral *
What do you consider to be the most challenging operations issue in your business today? *
What do you consider to be the most significant opportunity that you have not yet achieved? *
What is Your Primary Business Goal? *
Brief Description of your Business: *
