MBAC Business Intake Form

First Name:

Last Name:

Email:

Phone:

Street:

City:

State:

Zip:

County:

Business Name (If Applicable):

Are you currently in business? * This field is required

Date Business Established (If Applicable)

Years in business (If applicable)

Type of Industry (i.e. Construction, Health Care, Transportation) * This field is required

Please provide a FULL list of products or services you offer. (This information helps us connect you to opportunities/contacts in your scope of service) * This field is required

Business Address:

Street:

City:

State:

Zip:

County:

URL/Website (If Applicable)

Current Number of Employee(S) * This field is required

Average Yearly Gross Sales * This field is required

Owner(S) years of experience in field * This field is required

Have you done business with a Government Agency * This field is required

DUNS# (If Applicable)

UEI# (If Applicable)

NACIS# (If applicable please provide)

FEIN# (If applicable please provide)

Please complete the below demographic information so we can continue to get funding to provide free services to businesses

Gender * This field is required

Ethnicity * This field is required

Military Status * This field is required

Age * This field is required

Highest Education Achieved * This field is required

Income Level * This field is required

How did you learn about MBAC's counseling services * This field is required

Are there any additional services you would like to receive from: MBAC and/or NECIC

North End Community Improvement Collaborative
134 N. Main St., Mansfield, Ohio 44902

Phone: (419) 522-1611
Fax: 1 (877) 433-0848

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