Contact InformationFirst Name *Last Name *Email Address *Phone *How would you prefer we contact you? (Select all that apply): *EmailPhoneTextWhatsAppBusiness Street Address *Floor and/or Suite number (if applicable)CityState/ProvinceZIP / Postal CodeAbout YouHome Street Address *Apartment, suite, etcCityState/ProvinceZIP / Postal CodeDate of Birth *Preferred PronounsHe/HimShe/HerThey/ThemOtherGender / OrientationMaleFemaleNon-binary/ non-conformingPrefer not to answerDo you identify as LGBTQ+?YesNoPrefer not to answerRace/Ethnicity (check all that apply): *AfricanAfrican American / BlackAlaska NativeAsian or Pacific IslanderBlack/CaribbeanCaucasianHispanic/LatinXIndigenousMiddle Eastern / Arab AmericanNative AmericanOtherNumber of persons in your household (including yourself) *Household Income Range *Less than 24,00025,000 - 49,99950,000 - 99,999100,000 - 149,999150,000 - 199,999200,000 +How would you describe your educational background? Education level will not affect your eligibility into the program. *Some High School experienceCompleted High SchoolReceived my GEDSome College experienceCompleted 4-Year College Degree or Graduate School ProgramSome Trade School experienceCompleted Trade School ProgramHave you ever participated in a structured coaching program or business class before? (Y/N)YesNoAbout the BusinessBusiness Name *Business Phone *Website *Social Media LinksBusiness StructureSole ProprietorshipLLCS-CorpB-CorpC-CorpCooperativeOtherSelect Industry: *Select Industry:Accommodation/Food Service/HospitalityAdmin/Support/Waste Mgmt/Remed. SrvcsAgriculture/Forestry/Fishing/HuntingArts/Entertainment/RecreationClean EnergyConstructionCross-IndustryEducational ServicesFinance & InsuranceHealthcare & Social AssistanceInformationManagement of Companies & EnterpriseManufacturingMining/Quarry/Oil & Gas ExtractProfessional, Scientific & Technology ServicesReal Estate/Rental/LeasingRetailTransportation & WarehousingUtilitiesWholesale TradeOther Services (except Public Admin)How many people are in the business management team? *Name(s) of co-owner(s) or manager(s)Briefly tell us about your product or serviceWhen did the business start operations? *How many employees do you have, including yourself? *What was the business's gross revenue last year? (Exact amount as it appears on the business tax form)Business Goals and Program AlignmentWhat are you looking to achieve through this program? What do you hope to accomplish after the program has been completed? *Does your business have any private, state, or federal certifications? If yes, please list them.How did you hear about this program? *Email Newsletter from BIIEmail from another organizationA colleague/friend referred meBII’s websiteOnline searchOtherI AGREE TO: *Attend the program/event I am registering for and provide a company logo and photo for marketing purposes. If I cannot attend, I will notify Boston Impact Initiative (BII) at least 1 week before the start of the program. Maintain professionalism and respect for all BII staff members, volunteers, contractors, and fellow program attendees and participants. Maintain respect for all property and physical spaces where BII’s programs/events are hosted. Respect the choices and opinions of BII staff members, volunteers, contractors, and fellow program/event attendees and participants. Support BII’s mission by actively and positively promoting BII programs and services to your network through various methods such as social media and networking. Participant SignatureYour browser does not support e-Signature field.Apply