Ikanstart

Name *

First

Last

Company (If applicable): *

Address: *

Email: *

Phone Number: *

1. Does your business employ five or fewer people, including the owner? *

NO
YES – IF YES, you will be asked for supporting documentation to verify the information and can include: tax returns, bank statements, etc.

2. What is your Annual Household Income? *

3. What is your Household Size (how many members in the family): *

4. What is your Race/Ethnicity (select all that apply): *

5. Provide a short summary of the goods and services offered by your business. *

6. Provide a short summary of the area you serve and the products and services that you offer. *

CERTIFICATION & SIGNATURE *

I certify that this information is complete and accurate. I agree to provide, upon request, documentation for all income sources to the Program Administrator.

Today's Date *