subject_line
Fireside Chat w/ Gallup Chair Jim Clifton
I. Participant Information
Business Name:
*
Phone Number
*
Business Address
Street
*
City
*
State
*
Zipcode
*
Councilmanic District Number:
Contact Person
Name | Title
*
Email Address
*
II. Business Information
Date Business established:
*
+
Industry Type:
*
Accounting/ Finance/Legal Services
Building and construction
Building maintenance/ Pest Control
Computing and IT
Consulting
Childcare/ Daycare (Adult, childcare, and senior living)
Cleaning / Janitorial
Electrical/ Electronics
Environmental Technology and Services
Financial Services/ Investments
Food and Hospitality
Professional Services
Recruiting and Training
Health care
Manufacturing
Mixed businesses (groceries, small goods, etc)
Home improvement
Marketing
Real Estate and property management
Telecommunications
Transport
Other
Revenue
*
$0 - $250K
$250K - $500k
$500 - $2M
$2M+
Number of Full Time Employees
*
III. Ownership
Form of Ownership:
*
Sole Proprietor
Limited Liability Corp
Partnership
Corporation
Other
IV. Ethnic Identification
The following questions are for gathering statistical data only. If the business is owned and controlled primarily by individuals who are identified in any of the following categories, please check all the categories that apply:
*
African American/Black-Owned
Asian/Pasific Islander-Owned
Caucasian-Owned
Hispanic/Latino-Owned
Native American-Owned
Minority-Owned
Woman-Owned
Veteran-Owned
Certified MBE
County-Based