Survey : Questions

	Session dates: Fri., June 8 & 15, 2012, 9am-4pm All classes will be held at Carroll Community College, Scott Center building.

Please enter the information indicated below.

First Name:
Last Name:
Company Name:
Work Phone:
Email Address:	emailaddress@xyz.com
Address 1:
Address 2:
City:
State/Province (US/Canada):
Postal Code:

2.	Cell Phone #
	50 characters left.

3.	County:
	50 characters left.

4.	Are you the business owner? If not, please list your job title.
	50 characters left.

5.	Are there any other individuals involved in key decision making, e.g. spouse or partners? If so, list them.
	350 characters left.

6.	Last 12 Months' Revenue (in dollars): $
	50 characters left.

7.	Year Formed
	50 characters left.

8.	Type of business (e.g. manufacturing, wholesale, retail, professional service, etc.):
	50 characters left.

Primary Market

Large Corporations

Small Businesses

Consumer

Government

International

10.	Products / Services
	350 characters left.

11.	How are you different from your competition?
	350 characters left.

	Employee Count:

12.	Full-time
	50 characters left.

13.	Part-time
	50 characters left.

14.	1099 Contracted Personnel
	50 characters left.

Does your business have Accountant Prepared Financial Statements? (These will not be shared with the group but you will need this data to complete various exercises)

Yes

No

Are you committed to attending all sessions?

Yes

No

After the program, are you committed to spending time each week to implement your plan?

Yes

No

18.	Briefly describe what you hope to gain from participating in this program, or describe the greatest concerns, questions, threats or opportunities currently facing your business.
	350 characters left.

How did you learn about this program?

Referred by SBDC staff

Website

Email

Other

Comment:
500 characters left.

You will be contacted by email about your selection into this program. We may conduct a phone interview to collect further information.

The selection committee will choose those accepted into this grant-funded program based on several factors including the goal of creating a non-competitive, effective group coaching environment. To insure quality the SBDC may only consider applications that are completed in full and which provide all required information. All responses remain confidential.