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Lexington Minority and Women Business Training Program Application

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Lexington Minority and Women Business Training Program Application

  1. 1. P a g e | 1 Lexington Minority and Women Business Training Program Application Please fill out all requested information below. All information will be considered confidential and will be used to determine the appropriate qualifications for the training program. Please print or type all information. Name: ______________________________________________________________ Title: _______________________________________________________________ Name of Business: ____________________________________________________ Address of Business: __________________________________________________ Business Phone: ____________ Fax ____________ E-mail __________________ Business Description: 1. Please give a detailed description of the type of products and/or services your business offers. ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ___________________________________________________________________ 2. Are you certified as one of the following? 3. Indicate applicant’s ethnic group: Y N (MBE) Minority Owned Business Enterprise Native American/Alaskan Native ______ Y N (WBE) Woman Owned Business Enterprise Asian ______ White ______ Y N (DBE) Disadvantage Business Enterprise Native Hawaiian/Pacific Islander ______ Y N (8 (a)) SBA 8 (a) Black/African American ______ 4. Are you Hispanic? Y N 5. Gender: Male________ Female_______ 6. Please list all owners and the percentage of the ownership in the business listed above: Name______________________________________________________% of Ownership_______ Name______________________________________________________ % of Ownership_______ Name______________________________________________________% of Ownership_______ 7. Number of employees 0 ___ 1-5 ___ 6-10 ___ 11-20 ___ 21-50 ___ 51 or more ___ 8. When was the business established? ____________ 9. Annual gross revenues for the previous three years? 2012_____2011______2010_____ 10. What is your expected annual volume this year: $__________________ 11. Do you have multiple locations? Yes____ No____
  2. 2. P a g e | 2 GOALS 12. To help us in determining how we can best assist your business, we would like you to describe your long and short-term goals for your company. Please rate the THREE most important objectives of your company with one being the most important. ______ Increase Revenue ______ Increase Profitability ______ Secure Government Contracts ______ Increase Employee Retention ______ Improve Efficiency ______ Raise Overall Business Acumen ______ Increase Cash Flow ______ Do More Corporate Work ______ Grow Client Base ______ Have More Leisure Time ______ Secure a Business Loan Other_______________________________ Workshop Location: Fifth Third Bank 900 Beasley Street, 2nd Floor Lexington, KY 40509 Start Date & Time: Wednesday, September 25, 2013 9:00 am – 12:00 pm Cost: $50.00 (Payable September 25, 2013; contingent on program acceptance) APPLICATION DEADLINE: September11, 2013 All accepted applicants will be notified prior to the start of the training. Mail, fax or e-mail your Application for Admission to the following: Marilyn Clark Minority Business Enterprise Liaison LFUCG Division of Central Purchasing 200 East Main Street, Room 341 Lexington, KY 40507 (859) 258.3323 Fax: (859) 258-3322 E-mail: mclark@lexingtonky.gov Dee Dee Harbut Director of Special Programs Kentucky Small Business Development Center 1 Quality Street, Suite 635 Lexington, KY 40507

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