Are you self certifying as a business or individual? Please select Business Individual Other
First Name
Last Name
Address
Enter City, Sate, Zip
Email
Do you live in public housing or section 8 community? Please select Yes No
What current programs do you receive? TANF SNAP Medicaid Disability/SSI/SSD Other Other
What is your annual income? Please select <$25k $25-$50k $50-$75k $75-$100k $100k+ Other
Business Name
Business Street Address
Business City
State
Zip
Business Telephone Number
Business Website Address
Business Point of Contact
Business Email
Contact Phone Number
Number of Employees
NAICS
Year Business Established
What kind of contract would be best suited for your company? Please select Professional Services Construction related Administration Other Other
Choose Your Industry -- Please Select -- Construction Professional Services Administrative Management Other Other
Is your business searching for new contracts/opportunities? Please select Yes No Other
Social Media Handles (Names)
Facebook
Twitter
LinkedIn
Other
Are you currently enrolled in the FSS Program? Please select Yes No On Waiting List
What is your age? Please select 17 or younger 18-20 21-29 30-39 40-49 50-59 60 or older
What is the highest level of school you have completed or the highest degree you have received? Please select Less than high school degree High school degree or equivalent (e.g., GED) Some college but no degree Associate degree Bachelor degree Graduate degree
Which of the following categories best describes your employment status? Please select Employed, working 40 or more hours per week Employed, working 1-39 hours per week Not employed, looking for work Not employed, NOT looking for work Retired Disabled, not able to work
List any barriers to employment and or education, if any: Please select Criminal Background Child Care Transportation Mental Health Needs Other Other
How much total combined money did all members of your HOUSEHOLD earn last year? Please select $0 to $9,999 $10,000 to $24,999 $25,000 to $49,999 $50,000 to $74,999 $75,000 to $99,999 $100,000 to $124,999 $125,000 to $149,999 $150,000 to $174,999 $175,000 to $199,999 $200,000 and up Prefer not to answer
Are you currently enrolled as a student? Please select Yes, full time in graduate school Yes, part time in graduate school Yes, full time at a four year undergraduate college/university Yes, part time at a four year undergraduate college/university Yes, full time at a two year undergraduate college/university Yes, part time at a two year undergraduate college/university Yes, at a high school or equivalent No, I am not currently enrolled as a student
Choose a goal you would like to work towards: Education (obtain GED, certification and or degree) Entrepreneurship (start or grow a small business) Equity (Purchase your first home) Employment (increase my earning, get promoted or switch careers) Other Other
List CURRENT Skills, trades and or certifications that you possess or will possess soon: Adminsitrative/ Office Support Barber/Hair Stylist/Cosmetology License Book-keeping/Accounting Bus /Truck Driver Carpentry Certified Nurses Assistant (CNA) Construction Cooking/Catering Degree or License CDL (Commercial Driver's License) Data Entry Drywall Electrical Graphic Artist Home Health Aide HVAC Landscaping Maintenance Martial Artist Masonry Media Production Medical Assistant Military Nursing Painting Plumber Property Management Real Estate Retail Security Officer Sports/Recreation Tattoo Artist Teacher Teacher's Aide Uber Video Broadcasting Other Other
I agree that the information in this form is true and exact to the best of my knowledge and that my income is considered Low or Very-Low as per the definition of very low income as defined in Section 3(b)(2) of the 1937 Act, as established at HUD Income limits. I agree that the information in this form is true and exact to the best of my knowledge. I also certify that my business is considered a Section 3 Business Concern because it is at least 51 percent owned and controlled by low- or very low-income persons; or Over 75 percent of the labor hours performed for the business over the prior three-month period is performed by Section 3 workers; or It is a business at least 51 percent owned and controlled by current public housing residents or residents who currently reside in housing assisted by Section 8.
