REQUEST FOR MEDA SERVICES In order to best meet your needs as an entrepreneur, we assess your registration information and choose the resources that fit your stage of business development. All of the information asked for below helps us do this.Please take time to fully describe your business and your specific business needs. Meda has a high demand for services and we work with community partners to serve you as quickly as possible. Your information is confidential and will only be used to assess your business needs. Thanks for understanding and for giving us the most complete information you have. BUSINESS DESCRIPTION What is the legal name of your business? "Doing Business As" name(s)? Which of these best describes your business?Exploration/Pre-Launch -- at the idea stageStartup -- not yet earning revenue; developing business planGrowth -- earning revenue; establishing operationsMaturity -- operating for several years; leadership and structure well in placeExit/Succession Planning -- thinking about selling, changing leadership, or closingAcquisition/Merger -- interested in purchasing a business or merging businesses What is the legal structure of your business?Please select... Corporation LLC or LLP Partnership Sole Proprietorship Native American Tribal Corporation In what industry does your business operate?Please select... Professional, Scientific, and Technical Services Accommodation and Food Services Health Care and Social Assistance Construction Manufacturing Wholesale Trade Retail Trade Utilities Transportation and Warehousing Information Finance and Insurance Management of Companies and Enterprises Administrative Support and Waste Management Educational Services Real Estate Rental and Leasing Arts, Entertainment, and Recreation Agriculture, Forestry, Fishing and Hunting Mining, Quarrying, and Oil and Gas Extraction Other Services Public Administration Briefly describe your products/services: INFORMATION ABOUT YOU First Name Last Name Title What percent of the business do you own? % Enter a value from 0 - 100. Street Address (Home) Suite/Unit City StatePlease select... AK AL AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY ZIP Code Email Address Which category describes you?Please select... American Indian or Alaska Native Asian Black or African American Hispanic, Latino, or Spanish Middle Eastern or North African Native Hawaiian or Other Pacific Islander White What is your highest level of education?Please select... High School or GED Technical/Vocational College Post Graduate What is your gender?Please select... Female Male Prefer not to respond Other Do you rent or own your home?Please select... Rent Own What is your gross monthly household income?Please select... less than $1000 $1000 - $1999 $2000 - $2999 $3000 - $3999 $4000 - $4999 $5000 - $5999 $6000 - $6999 $7000 - $7999 $8000 or greater Number of people in your household Were you born in the US?Please select... Yes No Do you consider yourself a person with a disability?Please select... No Yes Choose not to respond Current military status?Please select... None Member of Active Duty Reserve or National Guard Choose not to respond Veteran status?Please select... Non-Veteran Service-Disabled Veteran Veteran Choose not to respond BUSINESS CONTACT INFORMATION Street Address Suite/Unit City StatePlease select... AK AL AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code Phone Business Website EXISTING BUSINESS INFORMATION When did you start your business? Please enter the date when you registered your business with the state. For your most recent full business year, what was your Gross Revenue/Sales? For your most recent full business year, what was your Profit/Loss? EMPLOYEES For your most recent full business year, what was your total number of employees, including the owner? How many are full-time? How many are part-time? How many identify as minorities? SERVICES Which of our services are you interested in?MarketingStrategyOperationsHuman ResourcesFinanceLending/Capital How did you hear about Meda?Please select... Nonprofit Organization Newspaper/Other Print/TV Meda Client Bank Government Agency Meda Employee Web Search Another Website Other Please specify how you heard about Meda: reCAPTCHA helps prevent automated form spam. The submit button will be disabled until you complete the CAPTCHA. Contact Information