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Participant Information
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Name
(Required)
First
Last
Participant Address
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Street Address
Address Line 2
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ZIP Code
How did you hear about us?
Participant Email
(Required)
Participant Phone
(Required)
Participant Status
(Required)
-
Entrepreneur – Wanting to Start a Business
New Business Owner – Under 2 years in business
Existing Business – More than 2 years in business
Race / Ethnicity
OPTIONAL
American Indian or Alaska Native
Asian
Hispanic
Black or African American
Hasidic Jewish
Native Hawaiian or Other Pacific Islander
Caucasian/White
Other
Prefer Not to Say
Other
Gender
(Required)
-
Male
Female
Other (Non-binary)
Prefer not to answer
Business Information
Name of Your Business
What is your current business formation?
(Required)
-
Sole Proprietorship
Limited Liability Company
Limited Liability Partnership
None of the Above, Start-Up
Community Partner
Other
Not Sure
Other
What industry or industries is your business in or is anticipated to be in (ex. Construction, Information Technology, Professional Development)?
Please specify:
Select all the ways you qualify as a socially or economically disadvantaged entrepreneur or business owner:
(Required)
Membership in a group that has been subjected to racial or ethnic prejudice or cultural bias within American society
Gender
Sexual Orientation
Religion
Limited English Proficiency
Veteran Status
Disability
Membership in a federally or state-recognized Indian Tribe
Residence in a U.S. Territory
Residence in a rural community
Residence in region adversely affected by persistent poverty or inequality
Residence in a community undergoing economic transitions (including communities impacted by the shift towards a net-zero economy or deindustrialization)
Membership in an underserved community
Residence in a Community Development Financial Institution (CDFI) Investment Area (as defined in 12 C.F.R. § 1805.201(b)(3)(ii))
Owning a business that is located in or will build, open, or operate a location in a CDFI Investment Area
Other
None of the above groups
Attestation Statement
(Required)
The Arizona Hispanic Chamber of Commerce, as a recipient of the United States Department of Commerce – Minority Business Development Agency (MBDA) Capital Readiness Program, requires all participants to (a) acknowledge they are receiving services under the Capital Readiness Program, (b) provide company
contact and profile information, (c) disclose outcomes(s) based on the services provided, (d) if requested, provide documentary verification. Under this agreement, the participant certifies that it is a business owned or controlled by Socially and Economically Disadvantaged Individuals (SEDI businesses), including the following –
a business that is owned and controlled by individuals or whose current majority founders are individuals who have had their access to credit on reasonable terms diminished compared to others in comparable economic circumstances, due to their:
membership in a group that has been subjected to racial or ethnic prejudice or cultural bias within American society
gender
veteran status
limited English proficiency
disability
long-term residence in an environment isolated from the mainstream of American society
membership in a federally or state-recognized Indian Tribe
long-term residence in a rural community
residence in a U.S. territory
residence in a community undergoing economic transitions (including communities impacted by the shift towards a net-zero economy or deindustrialization) or
membership in an underserved community
a business enterprise that certifies that it is owned and controlled by individuals whose residences are in Community Development Financial Institution (CDFI) Investment Areas, as defined in 12 C.F.R. § 1805.201(b)(3)(ii)
a business enterprise that certifies that it will build, open, or operate a location in a CDFI Investment Area, as defined in 12 C.F.R. § 1805.201(b)(3)(ii)
a business enterprise that certifies that it is located in a CDFI Investment Area, as defined in 12 C.F.R. § 1805.201(b)(3)(ii)
Underserved communities are populations sharing a particular characteristic, as well as geographic communities, that have been systematically denied a full opportunity to participate in aspects of economic, social, and civic life because of, for example: race, color, religion, sex, sexual orientation, gender identity, disability, residence in a rural community; and persistent poverty. See 31 C.F.R. 35.27(g)(11)(ii). “Underserved communities” includes Black, Latino, and Indigenous and Native American persons, Asian Americans and Pacific Islanders, and other persons of color; members of religious minorities; lesbian, gay, bisexual, transgender, and queer (LGBTQ+) persons; persons with disabilities; persons who live in rural areas; and persons otherwise adversely affected by persistent poverty or inequality. (See 31 C.F.R. 35.27(g)(11)(ii))
All information will remain confidential. In providing services to Capital Readiness Program participants, the Arizona Hispanic Chamber of Commerce and the United States Department of Commerce – Minority Business Development Agency does not guarantee any particular outcome or business decision - and is not liable for any outcomes or business decisions.
I agree to the Attestation Statement.
Signature (Type your name)
(Required)
Date
(Required)
Signature
(Required)
By signing your name, you are officially acknowledging the noted Formal Attestation Statement.
Your Name
Your Name
Your Name
Your Name
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