Pandemic Recovery Intake Form To complete this form in Spanish click here / Para completar este formulario en español, haga clic aquí Your Contact Information First Name Last Name Home Street Address (include Apt #) City StatePlease select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau Zip Code Country Email Cell Phone Home Phone I would like Rising Tide Capital to send me text message with updates, event reminders, and important news. Message and data rates may apply.Please select... Yes No More Information About YouSo that we can serve you best, we are going to ask some questions about your interests and needs What type of Service/Support are you interested in? (please select all that apply)Please select... Small Business Administration Economic Injury Loan (SBA EIL) Small Business Administration Payroll Protection Porgram (SBA PPP) NJEDA Small Business Emergency Assistance Loan Program Other What language would you prefer to have coaching in?Please select... English Spanish Either English or Spanish What is your first language?Please select... English Spanish Other Detail of other first language What gender do you identify as?Please select... Female Male Third Gender/Non Binary EthnicityPlease select... Hispanic Origin Non-Hispanic Origin Race (please select all that apply)Please select... Asian American Indian or Alaska Native Black or African American Native Hawaiian or Pacific Islander White or Hispanic Decline to answer Business Information What is the name of your business? Please provide a BRIEF description of your business (500 character max) Please provide the physical address your business operates from. If you operate from your home, please use that address. Business Street Address Business City Business StatePlease select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau Business Zip Business Email Address Business Phone Number Business Detail The following questions we are required to ask about your business to assess your eligibility for disaster relief assistance. Again, all data is kept confidential Is your business a for profit or not for profit entity?Please select... For Profit Not For Profit Business Employer Identification Number (EIN) Business NAICS Code (if known). You can look up codes here: https://www.naics.com/search/ Is this business currently registered as a Small Business Entity (SBE) with the state of NJ?Please select... Yes No Please identify the certifications As the business owner, do you work on this business full-time (at least 40 hours per week) or part-time?Please select... Full-time Part-time Does the business have any paid employees, other than yourself?Please select... Yes No Number of Full-time employees Number of Part-Time employees 2019 Total Gross Sales Total Cost of Sales for 2019 or the amount of money you spent on strictly producing the total number of units of your product or delivering your service for 2019 Are you currently making any sales?Please select... Yes No How Did You First Hear About Us? How did you first hear about Rising Tide Capital?Please select... My friend/family graduated from program I saw an ad on public transportation I saw a newspaper ad I saw a Facebook or Instagram post I was tagged on social media You sent me an email I did an online search Another organization referred me I picked up a flyer about your services I saw you at an event I read an article online I saw a newspaper/magazine article I walked by your office Other (please specify) Please specify detail of how you heard about us
