I. Participant Information

Business Name: *

Cell Phone Number *

Business Address

Street *

City *

State *

Zipcode *

Councilmanic District Number:

PLEASE BRING YOUR COMPUTER TO CLASS - In order to be able to provide you internet access on the days of the training, we need you to provide the following:

Contact Person

Name | Title *

Email Address *

Cell Phone Service Provider *

II. Business Information

Date Business established: * +

Industry Type: *

Revenue *

$0 - $250K

$250K - $500k

$500 - $2M

$2M+

Number of Full Time Employees *

How many individuals within your Household have a disability? *

Why do you want to be a part of this Program? *

Do you anticipate creating any additional full time jobs as a result of participating in this program? *

III. Ownership

Form of Ownership: *

Please List All Owners

	Name	Title	% of Ownership	Email
1.	Name	Title	% of Ownership	Email
2.	Name	Title	% of Ownership	Email
3.	Name	Title	% of Ownership	Email
4.	Name	Title	% of Ownership	Email

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: *

Submit Payment

AI Empowerment Training Course *

($30.00 + $3.00 processing fee)