Rising Tide Capital | CBA Application Save my progress and resume later | Resume a previously saved form Resume Later In order to be able to resume this form later, please enter your email and choose a password. Your Email: A Password: Confirm Password: Password must contain the following: 12 Characters 1 Uppercase letter 1 Lowercase letter 1 Number 1 Special character Hidden System Fields Contact ID Merged?YesNo CBA Application For First Name Last Name Not You? Click HereIf you have any questions, or if your name is spelled incorrectly, please call (201) 432-4316 or email: applications@risingtidecapital.org First Name Last Name Contact Information Address (Include Apartment Number) City State Zip Code Email Home Phone Cell Phone I would like Rising Tide Capital to send me text messages with updates, event reminders, and important news. Message and data rates may apply. YesNo I have read and agree to Rising Tide Capital’s privacy policy and terms of use Emergency Contact In the case of an emergency, who should we contact? (providing this is optional) Emergency Contact Name Emergency Contact Relationship Emergency Contact Phone Please Indicate Your First, Second, and Third Class Time Preferences First Choice Second Choice Third Choice DEMOGRAPHIC & HOUSEHOLD INFORMATION The following questions are asked so that we can provide the best possible services and for our internal purposes only. Our mission covers services to traditionally marginalized groups so we ask these questions to ensure we are reaching certain populations. However please note your eligibility to take part in the program is NOT effected by your responses to ANY of these questions. Gender you identify asFemaleMaleNon-binary / Third GenderDecline to Answer Date of Birth MM DD YYYY EthnicityHispanic OriginNon-Hispanic Origin Race (Please select all that apply.)AsianBlack or African AmericanWhiteAmerican Indian or Alaska NativeNative Hawaiian or Pacific IslanderDecline to answer Please describe your national or ethnic background: (If you belong to more than one group, pick the one you MOST identify as)Please select... Afghan African American Afrikaner Albanian Algerian American Andorran Angolan Argentine Armenian Aromanian Aruban Asian Assyrian Australian/Indigenous Australian (Aboriginal) Austrian Azeri Bahamian Bahraini Bangladeshi Barbadian Basque Belarusian Belgian Belizean Bengali Berber Bermudian Boer Bolivian Bosnian Brazilian Breton British British Virgin Islander Bulgarian Burkinabè Burundian Buryat Cajun Cambodian Cameroonian Canadian Cape Verdean Caribbean/West Indian Catalan Celtic Chadian Chilean Chinese Chuvash Colombian Comorian Congolese Corsican costa rican Croatian Cuban Cypriot/Turkish Cypriot Czech Dane Dominican Dutch East Timorese Ecuadorian Egyptian Emirati English Eritrean Estonian Ethiopian Fijian Filipino Finnish French Georgian German Ghanaian Gibraltar Greek Grenadian Guatemalan Guianese (French) Guinea-Bissau national Guinean Guyanese Haitian Hispanic and Latino American Honduran Hong Konger Hungarian Hutu Icelander Igbo Indian Indigenous people of America (First Nation/Huaorani/Inuit/Metis/Native American) Indonesian Iranian/Persian Iraqi Irish Israeli Italian Ivoirian Jamaican Japanese Javanese Jewish Jordanian Karen Kazakh Kenyan Korean Kosovo Albanian Kurd Kuwaiti Lao Latvian Lebanese Liberian Libyan Liechtensteiner Lithuanian Luxembourger Macedonian Malawian Malay Malaysian Maldivian Malian Maltese Manx Māori Mauritian Mexican Moldovan Mongolian Montenegrin Moroccan Namibian Nepalese New Zealander Nicaraguan Nigerian Nigerien Norwegian Pakistani Palauan Palestinian Panamanian Papua New Guinean Paraguayan Peruvian Polish Portuguese Puerto Rican Quebecer Reunionnai Roma Romanian Russian Rwandan Saint Lucia Salvadoran Sami São Tomé and Príncipe Sardinian Saudi Scottish Senegalese Serb Sicilian Sierra Leonean Sikh Silesian Singaporean Slovak Slovene Somali South African Spanish Sri Lankan Sudanese Surinamese Swedish Swiss Syriac Syrian Taiwanese Tamil Tanzanian Tatar Thai Tibetan Tobagonian Trinidadian Turk Tutsi Tuvaluan Ugandan Ukrainian Uruguayan Venezuelan Vietnamese Welsh Yemeni Zambian Zimbabwean Zulu Do you identify yourself as a member of any of the following groups? Our mission includes helping people from these groups. A Person With a DisabilityPlease select... Yes No A Person Who is a VeteranPlease select... Yes No A Person With a Past BankruptcyPlease select... Yes No A Person Who is a RefugeePlease select... Yes No A Person With a Crime ConvictionPlease select... Yes No A Domestic Violence SurvivorPlease select... Yes No A Person Who Was Formerly IncarceratedPlease select... Yes No Were You Born Outside of The U.S.?Please select... Yes No Country of OriginPlease select... Afghanistan Albania Algeria Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Saint Eustatius and Saba Bosnia and Herzegovina Botswana Brazil British Virgin Islands Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo (Democratic Republic of the Congo) Congo (Republic of the Congo) Costa Rica Côte d'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic of Iran) Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia (Federated States) Monaco Mongolia Monserrat Montenegro Morocco Mozambique Myanmar Namibia Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria North Korea (Democratic People's Republic of Korea) Norway Oman Pakistan Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Republic of Moldova Reunion Romania Russia Rwanda Saint-Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin / Sint Maarten Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa Samoa, American San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia (the former Yugoslav Republic of Serbia) Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Syrian Arab Republic Taiwan Tajikistan Tanzania (United Republic of Tanzania) Thailand Timor Leste (West) Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City State (Holy See) Venezuela Vietnam Virgin Islands (US) Western Sahara Yemen Yugoslavia Zambia Zimbabwe Number of Years in The United States What is your first language?EnglishSpanishOther Which other language? What is the highest level of education you have completed?Please select... Less than High School GED High School Diploma Vocational/Technical Certificate 2-year College Degree 4-year College Degree Master's Degree or Above Other What is your current employment status? (Please select all that apply.)Employed Full-timeEmployed Part-timeSelf-employed Full-timeSelf-employed Part-timeUnemployedNot working due to injuryNot working by choice If you are employed, where do you currently work, and what is your job title? Have you ever worked as a manager or supervisor?Please select... Yes No Would you rate your credit as satisfactory?Please select... Yes No Do you have a personal checking or savings account?Please select... Yes No Do you have savings to start your business?Please select... Yes No Are you a current or former participant in an IDA Program?Please select... Yes No Who is the IDA sponsor? Do You Own a Home?Please select... Yes No Do You Own a Car?Please select... Yes No Do You Own a Working Personal Computer?Please select... Yes No Do You Have Reliable Access to The Internet?Please select... Yes No Are You Registered to Vote?Please select... Yes No Are You a Single ParentPlease select... Yes No Are You The Primary Income Earner in Your Household?Please select... Yes No Are You Currently Receiving TANF Benefits?Please select... Yes No Are You Currently Receiving Any Other Public Assistance?Please select... Yes No Public Assistance Type: (Please select all that apply.)State WelfareFederal WelfareSocial SecurityUnemploymentFood StampsHousing AssistanceOther Do You Have Health Insurance for Yourself?Please select... Yes No Where is Your Health Insurance From?Coverage through your employerCoverage through your spouse's jobCoverage through your businessCoverage through a private policyMedicaidMedicareFree state health insuranceCoverage through another source Are there other adults in your household, besides you?Please select... Yes No Are there children (Younger than 18) in your household?Please select... Yes No Number of Adults in Your Household (18+, Including Yourself) Number of Children in Your Household (Under 18) Do Other Members of Your Household Have Health Insurance?Please select... All Some None Birthdates of your children Child Birthdate 1 (MM/DD/YYYY) Child Birthdate 2 (MM/DD/YYYY) Child Birthdate 3 (MM/DD/YYYY) Child Birthdate 4 (MM/DD/YYYY) Child Birthdate 5 (MM/DD/YYYY) Child Birthdate 6 (MM/DD/YYYY) Child Birthdate 7 (MM/DD/YYYY) Child Birthdate 8 (MM/DD/YYYY) YOUR Income Last Month Your Salary from job(s) Your Self Employment income Your Unemployment Benefits Your Child Support/Alimony Your Social Security/Retirement Your Disability / Worker’s Comp Your Public Assistance Your Other Income OTHER ADULT(S) IN HOUSEHOLD - Income Last Month Their Salary from Job(s) Their Self Employment Income Their Unemployment Benefits Their Child Support/Alimony Their Social Security/Retirement Their Disability / Worker’s Comp Their Public Assistance Their Other Income To what extent does your current monthly household income enable you to cover your monthly expenses?CompletelyMostlyNot MuchNot at All YOUR Income Last Year Your Salary from job(s) Your Self Employment income Your Unemployment Benefits Your Child Support/Alimony Your Social Security/Retirement Your Disability / Worker’s Comp Your Public Assistance Your Other Income OTHER ADULT(S) IN HOUSEHOLD - Income Last Year Salary from job(s) Self Employment income Unemployment Benefits Child Support/Alimony Social Security/Retirement Disability/Worker’s Comp Public Assistance Other Income Did your personal or household income change significantly since last year, or do you expect it to change soon? If so, please explain. CBA PROGRAM FEE STRUCTURE The fee you will pay is determined by where you live and your household income. We will inform you which fee you will pay after we receive your application. The fees are as follows: Up to 80% Local HUD Median Income - $15081% to 150% Local HUD Median Income - $295 151% and above Local HUD Median Income - $375 You MUST provide the following income documentation:Proof of Current Personal IncomeProof of Current Household Income Income verification documents can include: W2, Payroll Stub, Benefit Letter/Documentation, Unemployment Documentation, Proof of Disability Payments or Personal Affidavit. If you believe paying the CBA Program Fee will be a financial hardship because of your current income status, choose Yes.Please select... Yes No RTC wants to make sure that entrepreneurs are able to access and experience our programs as fully as possible. Would you like to request assistance with using technology, and/or with obtaining a suitable digital device or internet connection?Yes I would like to request assistance on this matterNo, I do not require assistance Business Information Are you currently making any sales?YesNo Does your business have a name?YesNo Business Name Business Website Is the contact information of your business the same as your personal contact information?YesNo Business Phone Business Email Is the address of your business the same as your home address?YesNo Business Street Address City State Zip Code Business Details How long has your business been making sales?Less Than 1 Year1 Year2 Years3 Years or More What was the date of your first sale? (an approximate is ok) Have you registered your business?Please select... Yes No Do you have a separate bank account for your business?Please select... Yes No Where is your business located?Home-basedRented Space: RetailRented Space: OfficeOther Do you work Full-Time or Part-Time on your business?Please select... Full-time Part-time Do you pay anyone else to work for your business?Please select... Yes No Number full-time employees Number part-time employees Number contracted/temp employees Business Financials What were your total sales/gross revenue Last Month? What were your total sales/gross revenue Last Year? Are you able to pay yourself a salary OR pay any personal expenses from the business?Please select... Yes No If YES, how much did the business pay you Last Month? If YES, how much did the business pay you Last Year? Have you ever applied for a loan for your business?Please select... Yes No Have you ever received a loan for your business?Please select... Yes No Where was the loan from?Please select... Bank Family or Friends Credit Card Microloan Organization Other Describe Your Business/Business Idea Briefly describe the business/idea you will be working on in class. Please be sure to tell us what you are selling and whether or not you are already in business. Tell us why you want to start or expand this business. Do you have any work and/or educational experience related to your business idea?Please select... Yes No Please describe any work, life, education or family experience related to the business you are describing here. Please describe any skills or talents that will help you with this business. What do you want to learn from the Community Business Academy? What do you think are some of the challenges you will face starting or growing your business? Briefly tell us why you will be a great candidate for the Community Business Academy. SERVICE AGREEMENT BY SUBMITTING YOUR APPLICATION YOU ARE AGREEING TO THE FOLLOWING CONDITIONS YOU CERTIFY THAT IF ACCEPTED INTO THE COMMUNITY BUSINESS ACADEMY:You will be able to attend every class for the time slot chosenYou will arrive on time for each class You are able to attend for the entire length of the class You will complete and submit all take-home assignments You will pay the Materials & Registration Fee, in full, on the first day of class*You agree to participate in follow-up surveys conducted by Rising Tide Capital for the next 5 years All Services and Documents are provided by Rising Tide Capital, Inc. on an “as is” and “as available” basis without any express or implied warranties, representations, or guarantees of any kind, including, but not limited to, any of merchantability, fitness for a particular purpose, title or non-infringement, or arising from course of dealing, trade, or performance. LIMITATION OF LIABILITY Neither Rising Tide Capital, Inc. nor its officers, directors, agents and employees, successors, assigns, agents and licensees (the “Rising Tide Capital, Inc. Parties”) shall be liable for any special, indirect, consequential, incidental, punitive or exemplary damages, even in the event of the foreseeability or advisement of such damages to or the negligence of the Rising Tide Capital, Inc. Parties, or in the event of a failure of essential purpose and regardless of the theory of liability. In no event shall Rising Tide Capital, Inc.’s liability to Client, even for direct damages, exceed $100. Client must bring any claim against the Rising Tide Capital, Inc. Parties within one (1) year of the event giving rise to Client’s cause of action, and failure to do so nullifies the claim. PAYMENT TERMS I understand that I am receiving subsidized services from Rising Tide Capital, Inc. and that if I accept admission into The Community Business Academy, I will pay a Materials & Registration fee of $150, $295 or $375, depending on my household income level. I will bring this Fee in full on the first day of class. Upon attending a minimum of one class of The Community Business Academy, this fee is non-refundable. RELEASE OF INFORMATION I give Rising Tide Capital, Inc. permission to release my personal and business information to its funding sources. I also give Rising Tide Capital, Inc. permission to use my personal and business information for program management and research purposes. I understand that the use of this information by Rising Tide Capital, Inc. will be limited to funding sources and research, unless otherwise required by law or to protect Rising Tide Capital, Inc.’s business interests. I agree to release any claims I may have against Rising Tide Capital, Inc. and its employees arising out of or related to the release of personal and business information as provided in this authorization. All of the application information is complete and accurate to the best of my knowledge. I understand that submitting this application does not guarantee acceptance into The Community Business Academy. PHOTO PERMISSION Submission of this application constitutes an agreement for Rising Tide Capital, or anyone authorized by Rising Tide Capital, to record and use, as Rising Tide Capital may desire in its sole and absolute discretion, all recordings and reproductions or depictions of such individual or attendees name, likeness, voice, persona, words, actions, and/or biography, which Rising Tide Capital or anyone authorized by Rising Tide Capital may make, including without limitation, the right to for Rising Tide Capital, or anyone authorized by Rising Tide Capital, to use such recordings, reproductions, or depictions in or in connection with any legitimate purposes, including for advertising, publicity, trade and editorial purposes, at any time in the future in all media now known or hereafter developed, throughout the world. I acknowledge that I will not receive any compensation of any kind for the use of my image, voice and/or biography as set forth above and hereby release Rising Tide Capital and/or its agents from any and all claims which arise out of or are in any way connected with such use. I have the right to contract in my own name. I have read this agreement and I fully understand it. This permission shall be binding on me and my heirs, legal representatives and assigns reCAPTCHA helps prevent automated form spam. The submit button will be disabled until you complete the CAPTCHA. Save my progress and resume later | Resume a previously saved form
