Business Name:

Description of Business:
(e.g. coffee shop, retail clothing store, lawyer office, auto mechanic, etc.)

Street Address:

City:

State:

ZIP Code:

Name of Primary Contact:

Title of Primary Contact:

Phone:

E-mail Address: (required)

Number of Employees:
Full-time:

Part-time:

What are your days/hours of operation?

Why did you choose this location for your business?

Please list the three issues which are most important to you as a business owner.
(e.g. health insurance, permitting, public safety, taxes, transportation)

Is your business willing to provide internships?

If so, would they be paid or unpaid?

Does your business require a special state license to operate?

If so, what kind?

General Comments:

(Please click only once)