Registration for

Future CEO Summer Program

Monday, July 10, 2023 10:00 AM to 3:00 PM Mountain

Location: Southern Colorado SBDC SBDC Classroom 121 W. City Center Dr, STE 200 Pueblo, Co 81003

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For all of the following questions, please answer regarding the existing or planned business that you would like counseling for.

First Name
Last Name
Zip Code	Enter your 5 digit Zip Code. If you don't have one or don't know your zip code, enter 00000

Business Name	Leave blank if you do not have a name chosen or the business name is the same as your name.
Position	Your position or title related to this business
Address	Your physical street address (number and street) of the business. If a home based business, or the business has not started yet, use your home address.
Address Line 2	Optional. Use for additional address postal information like apt, floor, suite, etc., or a PO Box.
City
State

Please enter contact information regarding this business so that we may contact you if necessary

Primary Phone	The best phone number (with area code) to reach you during our standard business hours. Include extension if necessary.
Primary Phone Type	Type of the primary phone above
Secondary Phone	A secondary phone number to contact you, if we cannot reach you at the primary number.
Secondary Phone Type	Type of the secondary phone above

Web Site	Web site URL for the business
Business Description	Brief three to five word description of the business

Please answer the following demographic questions about yourself.

Race	White Black Asian Native American/Alaskan Hawaiian/Pacific Check any that apply
Hispanic Ethnicity
Gender
Disability	Do you consider yourself a person with a disability
Military Status

Business Status

Business has started

Check if you have started conducting business. Leave unchecked if you are in the planning stages and have yet to start this business.

Since this business has started, please enter the following information.

Year Started	Year this business started
Month Started	Month this business started
Business Type	Primary category of business
Female Ownership %	% Enter the percent female ownership for this business.
Business Online	Yes If business is conducted online
Home Based Business	Yes If business is home based
DBE Certified	Yes If you are currently DBE Certified.
ESB Certified	Yes If you are currently ESB Certified.

Business Organization

Legal entity of the business

Employees FT

Current Number of Full Time Employees

Employees PT

Current Number of Part Time Employees

Annual Sales $

Annual Sales $ for the most recent full business year

Are you currently exporting

Yes

Export Employees	Current Number of Total Export Related Employees
Export Sales $	Export Related Sales for most recent full business year
Export Countries	Countries you are currently exporting to. Start typing the name of the country and a list will appear to choose from. You may select more than one.

How did you hear about us?
Other Event & Workshop Interests	Business Plans Business Startup Exporting Financing Marketing Quickbooks Please check any other topics you are interested in

The SBDC is partially funded by the American Rescue Plan Act which was created to support Small businesses impacted by the pandemic. Can you certify that your business was negatively impacted in any of the following ways? Please select all of the options that most closely describe your situation (more than one can be checked)

COVID-19 Impacts

a) Starting new businesses or recently started business (after March 2020) due to household experiencing unemployment, food insecurity, and/or housing insecurity during the pandemic

b) Experienced or experiencing labor market shortages or other supply chain impacts

c) Adopted, or adopting safer operating procedures (e.g. purchasing personal protective equipment such as masks for employees, closing indoor seating, etc.)

d) Created or looking to create new sales channels as a result of pandemic shifts

e) Impacted by periods of closure caused by pandemic

f) Other pandemic related impacts not listed here

g) Revenues decreased during the pandemic

h) Expenses increased during the pandemic

i) This question is not applicable to my business and/or household

Check Any that Apply

Please read the following, enter your Full Name, and click Continue below to indicate your acceptance.

CLIENT RIGHTS and RESPONSIBILITIES

As a client of the Colorado Small Business Development Center Network (CSBDC), an accredited network by America's Small Business Development Centers (ASBDC), we'd like to advise you of certain rights and responsibilities you have as one of our clients.

You have a right to expect:

Prompt, courteous, and professional counseling services and to be advised if the CSBDC is unable to provide services within the time frame required. Be aware that due to the demand for our services, cases must often be prioritized by need and training may be recommended before consulting is provided.
All information shared with the CSBDC and any of its resources (staff, faculty, volunteers, and consultants) will be held in strict confidence. Information provided by you will not be used to the advantage of any staff member, consultant, other resource of the CSBDC or any third party.
Your client status with the CSBDC will remain confidential. No public use of your name, business name, address or phone number will be made without your prior written approval. Please note, however, the CSBDC is partially funded by the US Small Business Administration and a limited amount of information with respect to your client status - name, address, nature and scope of services - is provided to that agency.

Our role is to consult and assist small business owners and those planning to go into business. We will not make business decisions or judgements for you, though we will make recommendations and suggestions as appropriate. These will be based upon our best efforts to apply the experience and resources available, in order to assist you in making your own business decisions.

The CSBDC may charge reasonable fees for training programs, special services and publications; however, you have a right to feel secure that the CSBDC or its resources for normal consulting services will charge no fee. No fees may be paid to or accepted for consulting services. Also, no recommendations will be made as to the purchase of goods or services from any specific individual or firm with whom any CSBDC staff member or its resources have any financial, familial or personal interest.

The consulting services provided to you by the CSBDC are part of the effort of the Colorado Office of Economic Development and International Trade (OEDIT) to respond to the growing needs of the small business community. They are not intended to compete with, replace or be a substitute for services available from the private sector. Clients whose needs can be fully met by private sector practitioners or firms in an affordable manner will be encouraged to use those resources.

In consideration of the CSBDC furnishing you with management and technical assistance, you agree to waive all claims against the CSBDC and its constituent institutions, its staff and any other resources employed by or used in connection with these services. You will be expected to cooperate with the CSBDC in its efforts to assure quality and effectiveness of consulting services which it provides.

In this respect, the CSBDC will ask all clients who received consulting assistance or attended training programs to complete an evaluation of services provided. In addition, all clients who receive two or more hours of consulting assistance may be asked to complete a brief "impact" assessment within one year following the close of a case file. Finally, clients may receive direct inquires from this office, the state director's office, the US Small Business Administration, or third party evaluators contracted by the CSBDC with respect to the services provided to you. Your response to all these inquiries will be greatly appreciated.

INFORMATION RELEASE

The CSBDC and the U.S. Small Business Administration (SBA) request your permission to share the success you receive through assistance of the SBDC/SBA. Your information may be used in articles, public service announcements, education, speeches, social media, blogs, etc. In addition, commercial or personal financial information obtained the CSBDC Network can be disclosed to prospective lenders for your business on your behalf at your request. The agreement to this is voluntary.

Please choose all that apply:

I hereby grant permission to the CSBDC/SBA to use the information herein for public information and educational purposes

I hereby grant permission to the CSBDC/SBA to use still photographs, audio and videotape and/or film of me, my business and its employees for public information and educational purposes

I hereby grant permission to the CSBDC to disclose personal and business financial information to prospective lenders for my business

I authorize CSBDC/SBA to furnish relevant information to the assigned management counselor(s). I further understand that the counselor(s) agrees not to: 1) recommend goods or services from sources in which he/she has an interest, and 2) accept fees or commissions developing from this counseling relationship. In consideration of the counselor(s) furnishing management or technical assistance, I waive all claims against CSBDC/SBA personnel, and that of its Resource Partners and host organizations, arising from this assistance.

Please enter your full name, indicating your acceptance of the above terms.

Full Name:

Date: 6/7/2023 11:34:29 AM

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