Applicants to the Program

APPENDIX A

APPLICATION PACKAGE

THIS PAGE IS INTENTIONALLY BLANK

The U.S. Department of Labor is sponsoring a study, called the Self-Employment Training (SET) Demonstration, to see how well a new program works to help unemployed workers and other interested individuals start or grow businesses in their fields of expertise. The study is being conducted by a team of researchers at Mathematica Policy Research.

To be able to apply to the SET Demonstration program, you must agree to be a part of this important study. By signing this consent form, you certify that you agree to take part in this study, which entails the following:

• In addition to this consent form, as part of the application materials for the SET Demonstration, you will complete a dislocated worker screening form, a “background information form,” a “business idea form,” and a “contact information form.” (You will be required to provide documentation to support your responses to questions regarding your worker status before being permitted to receive SET services). The research team will review these application materials to ensure that you are eligible for the SET demonstration. This application package will take about 60 minutes to complete.

• After you submit your complete application and are determined eligible for the SET Demonstration, a computer will assign you to one of two groups. One of the groups will have access to the SET Demonstration services at no cost to them for 12 months, and the other group will not have access to these services. Your assignment to one of these groups will be decided completely by chance. Even if you do not receive services, you will still be part of the study.

• Regardless of which group you are assigned to, the research team may contact you up to 60 months after applying to the SET Demonstration program to request that you complete online surveys. Survey questions will ask about your experiences with self-employment, including any services that you may have received to help you start or grow a business, your employment status, the success of your business venture, and other related topics. If you do not respond to the online survey, a Mathematica interviewer will contact you to offer the opportunity to complete the survey by telephone. Participation in this survey is voluntary, but it is very important to the success of the study.

• If you are assigned to the group that receives services through the SET Demonstration program, the study team might also contact you to request that you complete an additional interview (about one hour) asking about your experiences with the program and self-employment more generally. Participation in this interview is voluntary and will not affect your receipt of SET services.

• The research team may also contact federal and state agencies for information about earnings and benefits you may have received from other government programs. This information would be collected for a period covering up to two years before your date of application to the SET Demonstration program through eight years afterwards. This information would be used by the study team to study the effects of the SET program over time.

• All information that is collected about you through your application, surveys, interviews or agency records will be used for research purposes only. All information will be kept private by the research team, unless the law requires otherwise or you request release of your information in writing. Your name will never be used in any reports and no information will be reported in any way that could be used to identify you.

The decision to participate in the study is up to you. If you do not participate in the study, you cannot be considered to receive SET Demonstration services. However, this decision will not affect your eligibility for any work search or training services through American Job Centers or other programs. You may terminate your participation in the study at any time by writing to the Evaluation of the SET Demonstration, Mathematica Policy Research, P.O. Box 2393, Princeton, New Jersey 08543-2393. Any information that we collect about you prior to your termination request will be used for research purposes. If you have any questions about the application process or conditions for participation for the SET Demonstration, please call toll-free at 1800-951-7359or email SETDemonstration@mathematica-mpr.com.

I have read this consent form (or it has been read to me) and understand the conditions for participation in the SET Demonstration program. I understand the information provided in these materials and voluntarily agree to participate in the SET Demonstration.

__________________________________________

CUSTOMER’S NAME (Printed)

__________________________________________

LAST 4 DIGITS OF SOCIAL SECURITY NUMBER DATE

Reminder: If you are found eligible to receive program services and assigned to the SET program, you will be required to provide documentation supporting your responses to the questions below before receiving SET services.

1. Are you at least 18 years old?

 Yes 1

 No 0 GO TO NE1

2. Do you have United States citizenship, a green card, or a visa that makes you eligible to work in the United States?

 Yes 1

 No 0 GO TO NE2

3. Have you ever served in the U.S. Armed Forces?

Select one only

• I am currently on active duty in the U.S. Armed Forces (including activation from the National Guard or Reserve) 1 GO TO Q3a

• I served on active duty in the U.S. Armed Forces (including activation from the National Guard or Reserve), but have retired or been discharged 2 GO TO Q3b

• I am, or was, in the National Guard or Reserves but not on active duty 3 GO TO Q3b

• I have never served in the U.S. Armed Forces 0 GO TO Q3b

3a. Do you expect to be honorably discharged in the next six months?

 Yes 1 GO TO Q19

 No 0 GO TO NE3

P lease explain (STRING (NUM))

3b. Are you currently the spouse or widow of a current member or veteran of the armed forces?

 Yes 1 GO TO Q3c

 No 0 GO TO Q4

3c. Are you currently the spouse or widow of . . .

Select one only

 a member of the Armed Forces on active duty? 1

 a member of the Armed Forces who has been listed as missing in action, captured in line of duty by a hostile force, or forcibly detained or interned in line of duty by a foreign government or power for more than 90 days? 2

 a veteran who died of a service-connected disability? 3

 a veteran who has a total disability resulting from a service-connected disability, as evaluated by the Department of Veterans Affairs? 4

 a veteran who died while a total disability resulting from a service-connected disability was in existence? 5

 None of the above 6

IF Q3 = 1,2,3, GO TO Q6.

4. Are you a male born after December 31, 1959?

 Yes 1

 No 0 GO TO Q6

5. Have you registered with the Selective Service System?

 Yes 1

 No 0 GO TO NE4

6. Please describe your current employment situation.

Select one only

6a. Are you currently working?

 Yes 1

 No 0 GO TO Q12

6b. How does your current pay compare to what you usually made in the past?

 I did not previously hold a job 1

 I earn about the same or better monthly pay 2 GO TO Q7

 I earn less monthly pay 3 GO TO Q12

6c. Are you currently working because you used to be a homemaker, but are no longer supported by the income of another family member?

 Yes, I was a homemaker, but am no longer supported by the income of a another family member 1 GO TO YES1

 No 0

7. Is the company, factory, or store where you work closing permanently in the next six months?

 Yes 1 GO TO YES1

P lease explain (STRING (NUM))

 No 0

8. Have you received a notification that you are going to be laid off, fired, or otherwise have your position eliminated in the next six months?

 Yes 1

 No 0 GO TO Q12

9. Are you losing your job for reasons related to your job performance or conduct?

 Yes 1 GO TO NE5

P lease explain (STRING (NUM))

 No 0

P lease explain (STRING (NUM))

10. In the last three years, has there been a period of at least six consecutive months when you worked at least part time (20 hours or more a week) doing the same job for the same company? Please think of getting a promotion as still having the same job.

 Yes 1

 No 0 GO TO NE6

11. Within six months of losing your current job, how likely do you think you are to find another job in your usual line of work?

Select one only

 Very likely 1 GO TO NE7

 Somewhat likely 2 GO TO NE7

 Somewhat unlikely 3 GO TO YES1

 Very unlikely 4 GO TO YES1

P lease explain (STRING (NUM))

12. Are you currently receiving unemployment benefits?

 Yes 1

 No 0 GO TO Q.14

13. Do you think you are likely to find another job in your usual line of work in the next 6 months?

 Yes 1 GO TO Q.14

No 3 GO TO YES1

P lease explain (STRING )

14. We are interested in all of the ways that people work. Please select the option that best describes your last major work activity. (Please do not include any short-term jobs that you might have taken to help make ends meet.)

Select one only

 I worked for a civilian employer in a job for which I was paid a wage or salary 1 IF Q3c ≠1 AND

Q13=1 OR 2,

GO TO NE8. ELSE
IF Q3c=1, GO TO Q15. IF 3b ≠ 1, GO TO Q14b.

 I was self-employed. You can consider yourself to have been self-employed even if you did not make any or much money from the business. Please include work as an independent farmer, a rancher, or fisherperson. Also, please include businesses in which you were an owner or co-owner 2 GO TO YES1

 I was serving on active duty in the U.S. Armed Forces 3 GO TO Q.14a

 None of the above 0 GO TO NE9

P lease explain (STRING (NUM))

14a. Were you honorably discharged from the military?

 Yes 1 GO TO Q19

 No 0 GO TO NE10

P lease explain (STRING (NUM))

[Ask only if Q14=1 and Q3c=1]

14b. Did you leave your last job because your spouse permanently changed military stations or was discharged from the military?

 Yes 1 GO TO YES1

P lease explain (STRING (NUM))

 No 0

15. Did your last major job end because your company’s location, factory, or store closed permanently?

 Yes 1 GO TO YES1

P lease explain (STRING (NUM))

 No 0

16. Did your last major job end for reasons related to your job performance or conduct? Do not include reasons related to physical ailments.

 Yes 1 GO TO NE11

P lease explain (STRING (NUM))

 No 0

P lease explain (STRING (NUM))

17. When your last major job ended, did you collect unemployment benefits?

 Yes 1 GO TO Q19

 No 0

18. In the last three years, has there been a period at least six months long when you worked 20 hours or more a week doing the same job for the same company? Please think of getting a promotion as still having the same job. The six months need to be consecutive to say yes. (This need not be the same as your current job.)

 Yes 1

 No 0 GO TO NE6

IF Q14 = 3 OR Q3a = 1, GO TO Q19. ELSE GO TO Q19a.

19. Within six months of your discharge, how likely do you think you are to find another job in your usual field that matches your skill and experience level?

Select one only

 Very likely 1 GO TO NE8

 Somewhat likely 2 GO TO NE8

 Somewhat unlikely 3 GO TO YES1

 Very unlikely 4 GO TO YES1

P lease explain (STRING (NUM))

19a. Within six months of your discharge, how likely do you think you are to find another job in your usual field that matches your skill and experience level?

Select one only

 Very likely 1 GO TO NE8

 Somewhat likely 2 GO TO NE8

 Somewhat unlikely 3 GO TO YES1

 Very unlikely 4 GO TO YES1

P lease explain (STRING (NUM))

NOTIFICATION OF ELIGIBILITY STATUS.

INELIGIBLE:

Thank you for completing this screening form. At this time, . . .

NE1 - IF Q1=0: you are not eligible to apply to the SET Demonstration because you are not at least 18 years old. The program is intended to serve adults.

NE2 - IF Q2=0: you are not eligible to apply to the SET Demonstration because you are not legally eligible to work in the United States.

NE3 - IF Q6a=1: you are not eligible to apply to the SET Demonstration because you are currently serving in the military and do not expect to be honorably discharged from the military within the next 6 months.

NE4 - IF Q5=0: you are not eligible to apply to the SET Demonstration because you have not registered with the Selective Service System.

NE5 - IF Q9=1: you are not eligible to apply to the SET Demonstration because you are losing your job for reasons related to your job performance or conduct.

NE6 - IF [(Q10<6 months) or (Q18<6 months)]: you are not eligible to apply to the SET Demonstration because you do not have enough recent experience in any single line of work. The program is geared toward individuals with a more consistent work history.

NE7 - IF [Q11=1 or =2]: you are not eligible to apply to the SET Demonstration because you are likely to find a job that matches your work experience within six months of losing your current job. The program seeks to help individuals who face more substantial and long-term challenges in becoming reemployed.

NE8 - IF [((Q13=1 or 2) and Q14=3)) or (Q19=1 or 2)]: you are not eligible to apply to the SET Demonstration because you are likely to find a job that matches your work experience within the next six months. The program seeks to help individuals who face more substantial and long-term challenges in becoming reemployed.

NE9 - IF Q14=0: you are not eligible to apply to the SET Demonstration because you do not match any of the categories of ‘dislocated workers’ described at the orientation session.

NE10 - IF Q14a=1: you are not eligible to apply to the SET Demonstration because your last major work activity was military service, but you were not honorably discharged.NE11 - IF Q16=1: you are not eligible to apply to the SET Demonstration because you lost your last major job for reasons related to your job performance or conduct.

Please visit your local One-Stop Career Center to find out about other programs and services that you may qualify for. If you have any questions, please call the SET Demonstration toll-free at 1-xxx-xxx-xxxx or email SETDemonstration@mathematica-mpr.com.

ELIGIBLE:

YES1 - IF [Q7, Q11=3, Q11=4, Q13=3, Q13=4, Q14=1, Q14=4, Q14b=1, Q15=1, Q19=3, or Q19=4]: “Thank you for completing this screening form. Congratulations! Based on your recent work history, you are eligible to apply to the SET Demonstration. Please proceed to the application form.”

Application Form for the

Self-Employment Training (SET) DEMONSTRATION Program

[DOL, SBDC, and SET LOGOS TO BE INSERTED HERE]

Please answer all questions on this application as completely as possible. The information collected on this application will be kept private to the extent permissible under existing law and used only for research purposes.

Please note that in this application, “self-employment” can include business or entrepreneurial pursuits that represent your primary work activity or that you do on the side or in addition to wage or salary employment. You should consider yourself to be self-employed even if you made little or no money from the business venture. Also, please include business ventures in which you are not or were not the sole owner (that is, you are or were a co-owner or have or had business partners).

The application has several parts:

BACKGROUND INFORMATION FORM. This section asks about your personal background, living situation, and also about your work history and experience. There are no right or wrong answers to the questions asked in this form and your answers are important to help improve these types of programs.

BUSINESS IDEA FORM. This section tells us about the business that you hope to establish or grow and how it relates to your prior work experiences and/or field of expertise. Please describe your business idea and relevant background in as much detail as possible.

CONTACT INFORMATION FORM. This section asks for information that may help us contact you later for our survey on your experiences since applying to the SET program.

IF YOU HAVE ANY QUESTIONS, PLEASE CALL THE SET TEAM

TOLL FREE AT: 1-800-951-7359.

INSTRUCTIONS:

• When asked to enter a dollar amount, please round to the nearest dollar.

For example, for $279.82, enter $ | | | |, | 2 | 8 | 0 | DOLLARS

For $4,725.44, enter $ | | | 4 |, | 7 | 2 | 5 | DOLLARS

DEFINITIONS:

Q19 – Primary Language The language you speak most often at home.

Q35 – Unsecured Debt Debts where there is no collateral that is attached to that debt, unlike secured debt (such as a mortgage) where there are tangible items that are attached to the debt. Common examples of unsecured debts are credit cards, medical bills and student loans.

Q63 – Advisor/Counselor Someone you meet with regularly one-on-one to discuss your self-employment needs and progress, and helps link you to services or resources to start or expand your own business.

Q63 – Individualized Business Development Support One-on-one sessions focused on specific issues related to starting your own business, for example developing your business and marketing strategies, managing your finances, applying for loans or grants, hiring employees, using information technology, etc. Please exclude periodic meetings with an advisor/counselor to help determine assess your self-employment assistance needs, progress, or identify services that may be helpful to you.

Q63 – Peer Advice/Networking Group Groups in which you share ideas, strategies or information with other individuals who are self-employed or trying to start a business.

Q63 – Personal Mentors Experienced business owners who mentor you one-on-one as you develop your business idea, or start and grow your business.

Date of Application: | | | / | | | / | | | | |

Month Day Year

1.

Last Name First Name Middle Initial

2.

Street Address

Apartment Number

City State ZIP Code

3. NO QUESTION 3 IN THIS VERSION.

4. NO QUESTION 4 IN THIS VERSION.

5. Please list all of the e-mail addresses where you can be reached:

Email 1

Email 2

Email 3

0  I do not have e-mail

6. Do you or your business have a page on a social networking site (i.e. Facebook, LinkedIn, or Twitter) where you can be reached?

1  Yes (Please specify):

0  No

7. Social Security Number:

| | | | - | | | - | | | | |

8. Date of Birth: | | | / | | | / | | | | |

Month Day Year

9. Sex:

1  Male

2  Female

10. Home Phone Number (Landline):

0  None GO TO Q.12

(| | | |)-| | | |-| | | | |

Area Code

11. Whose name is that phone listed in?

1  My own name

First Name/Last Name

12. Cell Phone Number:

0  None GO TO Q.14

(| | | |)-| | | |-| | | | |

Area Code

13a. Does your cell phone plan have unlimited minutes?

1  Yes

0  No

13b. Does your cell phone plan have unlimited texting?

1  Yes

0  No

13c. May we send you text messages?

1  Yes

0  No

14. Is there another phone number where you can be reached?

(| | | |)-| | | |-| | | | |

Area Code

Ext.: | | | | |

0  None GO TO Q.15a, NEXT PAGE

15. That number belongs to:

MARK ONE

1  Friend

2  Relative

3  Neighbor

4  Landlord

5  Employer/Work Phone

6  OTHER (specify)

15a. Do you use any video calling services such as Skype, Oovoo, or FaceTime?

1  Yes (Please specify service and username):

0  No

16. Are you Hispanic or Latino?

1  Yes

0  No

Soft check: Pop up if 16 is not answered. Please answer BOTH question 16 about HISPANIC origin and question 17 about race. For this application, Hispanic origins are not races.

17. Which of the following describe your race?

	YES	NO
a. American Indian or Alaska Native	1 	0 
b. Asian	1 	0 
c. Black or African American	1 	0 
d. Native Hawaiian or Other Pacific Islander	1 	0 
e. White	1 	0 

Soft check: Pop up if 17 is not answered. Please answer BOTH question 16 about HISPANIC origin and question 17 about race. For this application, Hispanic origins are not races.

18. Are you a citizen of the United States?

1  Yes

0  No

19. What is your primary language?

MARK ONE

1  English

2  Spanish

3  OTHER (specify)

20. What is the highest grade of regular school or highest degree that you have completed?

MARK ONE

1  Up to 8th grade

2  9th to 11th grade

3  12th grade but no diploma

4  High school diploma

5  GED or high school equivalent

6  Some college but no degree

7  Associates degree (A.A., A.S.)

8  Bachelor’s degree (B.A., B.S.)

9  Masters degree (M.A., M.S.)

10  Professional degree after bachelor’s degree

11  Doctorate degree (i.e. PhD., Ed.D.)

21. In what field did you receive your highest degree?

22. Including yourself, how many adults currently live in your household? Please include all people who contribute to household finances, even if they are temporarily away.

| | | NUMBER OF ADULTS IN HOUSEHOLD INCLUDING YOURSELF

23. How many children under 18 years of age live with you in your household at least half the time? Please include biological and adopted children, as well as foster-, step-, and grandchildren.

| | | NUMBER OF CHILDREN

24. What is your marital status right now?

MARK ONE

1  Married/Civil Union

2  Living together unmarried

3  Separated

4  Divorced

5  Widowed

6  Never married GO TO Q.25, NEXT PAGE

25. Now think about your household’s total income during the past twelve months. Please count any income from self-employment, regular jobs, odd jobs, under-the-table jobs, and other work activities; income from Social Security, pensions, rent, interest and dividends, unemployment compensation, welfare, food stamps, child support, and income from any other sources for all members of your household.

In the last 12 months, what was your total household income from all sources before taxes and deductions? Please include income from yourself as well as all members of your household.

$ | | , | | | | , | | | | DOLLARS

26. Do you own your usual residence?

1  Yes

0  No GO TO Q.30

27. What is the current value of that property? (If the property were sold today, how much would it sell for? Your best estimate is fine.)

$ | | , | | | | , | | | | DOLLARS

28. Do you have a mortgage on this property?

1  Yes

0  No GO TO Q.30

29. What is the total remaining mortgage balance?

$ | | , | | | | , | | | | DOLLARS

30. Do you have money in checking or savings accounts or mutual funds (such as money market funds, CDs, savings bonds or Treasury bills)? Please do not include employer-based pensions or IRAs.

1  Yes

0  No GO TO Q.32

31. If you added up all such accounts, about how much would they amount to altogether right now?

$ | | , | | | | , | | | | DOLLARS

32. Do you have any credit cards or charge cards such as Visa, MasterCard or Discover? Please include store cards and gasoline cards.

1  Yes

0  No GO TO Q.35

33. After the most recent payments were made, roughly what was the total balance still owed on all these accounts?

$ | | | | , | | | | DOLLARS

34. What is the maximum amount you could borrow on all these accounts; that is, what is your total credit limit?

$ | | | | , | | | | DOLLARS

35. Do you have any loans or other unsecured debt where you currently still owe money? These may include personal or student loans, business or investment loans, medical bills, or child support. (Do not include home or car loans.)

1  Yes

0  No GO TO Q.37, NEXT PAGE

36. How much, in total, is still owed on all such loans?

$ | | | | , | | | | DOLLARS

37. Is anyone in your household currently receiving any of the following? Remember all of your responses will be kept private.

	YES	NO
a. Food Stamps or SNAP benefits	1 	0 
b. Welfare payments or other public assistance payments such as TANF or General Assistance	1 	0 
c. SSI (Supplemental Security Income) or SSDI (Social Security Disability Insurance)	1 	0 
d. Social Security benefits	1 	0 
e. EITC (Earned Income Tax Credit)	1 	0 
f. Housing assistance, such as Section 8 vouchers	1 	0 
g. OTHER (please specify)	1 	0 

38. [INTERVIEWER: ONLY ASK IF Q22 > 1] Besides yourself, how many adults in your household worked for pay or were self-employed, either part-time or full-time, over the last 12 months?

| | | NUMBER OF ADULTS

39. Do you or anyone else in your household have any disability or serious health problem that makes it difficult for you to work?

1  Yes, I have a disability or health problem that makes it difficult for me to work

2  Yes, someone else in my household has a disability or health problem that makes it difficult for me to work

3  Yes, someone else in my household and I both have a disability or health problem that makes it difficult for me to work

0  No

4 0. Do you currently have responsibilities for the care of children or other family members during the day that limit your ability to be self-employed or to run your own business?

1  Yes

0  No

41. Do you currently have access to reliable transportation?

1  Yes

0  No

42. Do you currently have access to a computer in your home?

1  Yes

0  No

4 3. Do you currently have internet access, either on a home or business computer or on a cell phone or other mobile device?

1  Yes

0  No

44. How would you rate your computer skills?

MARK ONE

1  Excellent

2  Very good

3  Good

4  Fair

5  Poor

45. Do you currently have health insurance coverage?

1  Yes

0  No GO TO Q.47

46. Where does this insurance come from?

MARK ONE

1  Your employer

2  A family member’s employer

3  Medicaid or another public health insurance

4  OTHER (specify)

47. Overall, how would you rate your current health status?

MARK ONE

1  Excellent

2  Very good

3  Good

4  Fair

5  Poor

48. What amount of financial risk you are willing to take when you save, or make investments?

1  Above average risks to earn above average returns

2  Average risks to earn average returns

3  Limited risks to earn limited returns

0  Not willing to take any financial risks

49a. Below, we list pairings of personality traits that may or may not describe you. Please select the response option that best describes the extent to which you agree or disagree that the pair of personality traits listed applies to you. You should rate the extent to which the pair of traits applies to you, even if one characteristic applies more strongly than the other.

	Disagree Strongly	Disagree Moderately	Disagree a little	Neither agree nor disagree	Agree a little	Agree Moderately	Agree Strongly
a. Extroverted, enthusiastic	1 	2 	3 	4 	5 	6 	7 
b. Critical, quarrelsome	1 	2 	3 	4 	5 	6 	7 
c. Dependable, self-disciplined	1 	2 	3 	4 	5 	6 	7 
d. Anxious, easily upset	1 	2 	3 	4 	5 	6 	7 
e. Open to new experiences, complex	1 	2 	3 	4 	5 	6 	7 
f. Reserved, quiet	1 	2 	3 	4 	5 	6 	7 
g. Sympathetic, warm	1 	2 	3 	4 	5 	6 	7 
h. Disorganized, careless	1 	2 	3 	4 	5 	6 	7 
i. Calm, emotionally stable	1 	2 	3 	4 	5 	6 	7 
j. Conventional, uncreative	1 	2 	3 	4 	5 	6 	7 

49b. Below are a number of statements that may or may not apply to you. Please select the response option that best describes the extent to which you agree or disagree with each statement.

	Disagree Strongly	Disagree Somewhat	Neither agree nor disagree	Agree somewhat	Agree Strongly
a. When I make plans I am almost certain that I can make them work	1 	2 	3 	4 	5 
b. Many of the unhappy things in life are partly due to bad luck	1 	2 	3 	4 	5 
c. Getting people to do the right thing depends upon ability. Luck has nothing to do with it	1 	2 	3 	4 	5 
d. Getting a good job depends upon being in the right place at the right time	1 	2 	3 	4 	5 
e. What happens to me is my own doing	1 	2 	3 	4 	5 
f. Many times I feel that I have little influence over the things that happen to me	1 	2 	3 	4 	5 

The next series of questions are about your motivation for pursuing self-employment and prior experiences as a business owner.

50. Why are you interested in being self-employed? Please mark the top three reasons.

MARK THREE REASONS

1  To have a primary source of income

2  To have a secondary source of income

3  To have work which conforms to your health limitations

4  To have work not available elsewhere in the job market

5  To have more freedom to meet family responsibilities

6  To bring a new idea to the marketplace

7  To advance in your profession

8  To be your own boss

9  Some other reason (please describe)

51. In the last 5 years, have you ever been self-employed or owned your own business?

1  Yes

0  No GO TO Q.65, NEXT PAGE

51a. How many businesses have you owned, or how many times have you been self employed, in the last 5 years?

| | | NUMBER

52. In the last 5 years, did you operate a business that . . .

	YES	NO
a. was incorporated? Please include C‑Corps, S. Corps, proprietorships, partnerships, and LLCs.	1 	0 
b. was registered with your state, county, or city?	1 	0 
c. had paid employees other than yourself? Please include co-owners if they were paid	1 	0 

53. Are you currently self-employed in your own incorporated or unincorporated business, professional practice, or farm?

1  Yes

0  No GO TO Q.56

54. Currently, do you operate a business that . . .

	YES	NO
a. is incorporated? Please include C‑Corps, S. Corps, proprietorships, partnerships, and LLCs.	1 	0 
b. is registered with your state, county, or city?	1 	0 
c. has paid employees other than yourself?	1 	0 

55. Over the last 12 months, how much were your net earnings from self-employment after business expenses, but before taxes and deductions were taken out? (If you lost money, please report loss as negative earnings.)

$ | | , | | | | , | | | | DOLLARS

1  Please check here if the amount you entered reflects losses from self-employment

56. In the last 12 months, how many weeks were you self-employed or a business owner?

1  52 weeks

| | | NUMBER OF WEEKS

57. How many hours per week did you usually work at all self-employment ventures in the past 12 months?

| | | | HOURS PER WEEK

58. Thinking about your current or most recent business venture, what did you make, sell, or do? (If you currently have or most recently had more than one business, please answer this and the following questions referring to the business that you considered to be your main business venture.)

59. When did you start that business or self‑employment venture?

START DATE: | | | / | | | | |

Month Year

60. When did you stop doing that business or self‑employment venture?

STOP DATE: | | | / | | | | |

Month Year

1  Still doing business

61a. Not including yourself, how many employees does this business currently employ?

| | , | | | | NUMBER OF EMPLOYEES

61b. What was the largest number of employees that this business has employed, not including yourself?

| | , | | | | NUMBER OF EMPLOYEES

62. (Are you providing/did you provide) yourself with any monetary compensation for running this business?

1  Yes

0  No

63. Have you ever participated in any of the following self-employment services or programs to help you start or grow a business?

	YES	NO
a. Working with a self-employment advisor or counselor	1 	0 
b. Individualized business development support on issues related to starting and/or expanding your own business	1 	0 
c. A peer advice or networking group for aspiring, new, or existing small business owners	1 	0 
d. Mentoring from an experienced business owner	1 	0 
e. In-person classes, workshops, or seminars on topics related to starting, operating, or growing a business	1 	0 
f. Online courses on topics related to starting, operating, or growing a business	1 	0 
g. Other self-employment services (please describe)	1 	0 

64. NO ITEM 64 IN THIS VERSION.

65. Have any relatives or close friends ever been self-employed or owned a business?

1  Yes

0  No GO TO Q.68

66. Did you ever work for or help out these relatives or friends at this business?

1  Yes

0  No

67. In the last 5 years, have you worked at a job for someone else where you received a salary or hourly wage?

1  Yes

0  No GO TO Q.74, NEXT PAGE

68. In the last 12 months, have you worked for someone else at a job where you received a salary or hourly wage?

1  Yes

0  No GO TO Q.74, NEXT PAGE

69. In the last 12 months, how long did you work at a salary or hourly-wage job for someone else?

1  All 12 months GO TO Q.70

| | | MONTHS

70. In the last 12 months, how many hours per week did you usually work at any or all jobs in which you worked for someone else for a salary or hourly wage?

| | | | HOURS PER WEEK

71. In the last 12 months, how much did you earn in total, before taxes and deductions, from wages and/or a salary while working at a job for someone else?

$ | | , | | | | , | | | | DOLLARS

72. Are you currently working for someone else in a job where you are paid a salary or hourly wage?

1  Yes GO TO Q.77a

0  No

73. If you are not working or a self-employed business owner, which of the following best describes your work-related activities over the past month? Were you…

MARK ONE

1  Retired

2  Unable to work because of a disability

3  In school or a training program

4  Unemployed on temporary layoff

5  Unemployed and looking for work

6  Unemployed and not looking for work

7  Caring for a family member

8  Doing something else (specify)

74. When did your last job end?

| | | / | | | | |

Month Year

75. Why did you stop working at your last job?

MARK ONE

1  Laid off

2  Business/plant closed

3  Temporary or seasonal job ended

4  Fired

5  Retired

6  Quit to start working for self

7  Quit for family reasons

8  Quit for another reason (specify)

76. When your last job ended, did you receive severance pay?

1  Yes

0  No

77a. About how long, in total, (did you work/have you worked) at your (most recent/current) job that is not self-employment?

| | | YEARS and | | | MONTHS

77b. How many hours per week (do/did) you usually work at that job?

| | | | NUMBER OF HOURS

77c. What kind of company (are you currently working for/did you last work for)? What do/did they make, sell, or do? Please describe.

78. What (do/did) you do there? What (is/was) your job title? Please describe.

79. If you answered yes to both question 53 and 72 (you are currently both self-employed and working for someone else), which do you consider to be your primary work activity?

1  Self employment

2  Working for someone else

3  Both are equal

80. Have you ever worked in a managerial capacity in any job, for someone else? By managerial, we mean a position in which you were directly responsible for overseeing business resources or the activities of other staff.

1  Yes

0  No GO TO Q.82

81. How long have you worked in a managerial capacity? (If fewer than one year, only enter months.)

| | | YEARS AND/OR

| | | MONTHS

82. Within the past 7 years, have you declared bankruptcy for yourself or your small business?

1  Yes

0  No

83. Within the past 3 years, on how many different credit payments, for yourself or your small business (if applicable), have you been 60 or more days delinquent? Please include mortgages, trade credits, and credit from suppliers.

If January and February mortgage payments were both 60 days late, this would count as two different payments.

0  None

1  One

2  Two

3  Three or more

84. Within the past 3 years, have you or your small business (if applicable) been required by a court order or lawsuit to make payments to a creditor?

1  Yes

0  No

85. In the last 24 months, how many weeks did you receive Unemployment benefits?

| | | NUMBER OF WEEKS IF 0, GO TO END

0  None GO TO END

86. Are you currently receiving Unemployment benefits?

1  Yes GO TO END

0  No

87. Have you exhausted your Unemployment benefits?

1  Yes

0  No

88. Thinking about your current or most recent spell of unemployment, how many weeks total did you receive Unemployment benefits?

| | | NUMBER OF WEEKS

This completes the Background Information Form. Thank you.

The information that you provide on this form will be very useful in determining whether you are a good fit for the program. It is very important that you provide as much detail as possible when answering the questions that follow.

1. Please describe, in detail, the business that you want to start or grow. For example, what will you make, sell, or do? Who will be your clients? Where and when will the business operate? Will you hire staff? How do you plan to develop or grow your business?

2. Please describe, in as much detail as possible, how this business idea relates to your prior work experience and your overall expertise. (Please see the Examples of Work Experience that Relate to a Business Idea sheet.)

3. Will any other individuals be involved in running this business with you? That is, will you have any business partners?

1 □ Yes

0 □ No GO TO Q.5, NEXT PAGE

4. Please list the names and contact information for all other individuals (that is, business partners) who are or will be involved in this business venture. Please include those who are in an existing partnership with you and are involved in the running of the business. Do not include people you employ or plan to hire.

A. Last Name First Name MI
Street Address
City State Zip Code
Home: (_______) - ________ - ____________ Area Code Number	Mobile: (_______) - ________ - ____________ Area Code Number	Office: (_______) - ________ - ____________ Area Code Number
Email Address
B. Last Name First Name MI
Street Address
City State Zip Code
Home: (_______) - ________ - ____________ Area Code Number	Mobile: (_______) - ________ - ____________ Area Code Number	Office: (_______) - ________ - ____________ Area Code Number
Email Address
C. Last Name First Name MI
Street Address
City State Zip Code
Home: (_______) - ________ - ____________ Area Code Number	Mobile: (_______) - ________ - ____________ Area Code Number	Office: (_______) - ________ - ____________ Area Code Number
Email Address

5. Are you already working on or running this business?

1 □ Yes

0 □ No GO TO Q.8

6. For how long have you worked on the business?

| | | YEARS AND/OR | | | MONTHS

7. Is this business…

	SELECT ONE RESPONSE PER ROW
	YES	NO
a. registered with your state?	1 □	0 □
b. registered with your county?	1 □	0 □
c. registered with your city?	1 □	0 □
d. incorporated? Include C-Corps, S. Corps, and LLCs.	1 □	0 □
e. a sole proprietorship?	1 □	0 □
f. a partnership?	1 □	0 □

8. Not including yourself, how many employees does this business currently employ?

| | | NUMBER OF EMPLOYEES

9. Do you have a written or formal business plan for this business?

1 □ Yes

0 □ No

10. Have you (ever) worked previously in a business (or job) whose goods or services were similar to those that your proposed business will provide (or currently provides)?

1 □ Yes

0 □ No

CONTACT INFORMATION FORM

Y our Name: first middle initial last

Date of Birth: | | |/| | |/| | | | | Month Day Year

Today’s Date: | ­ | |/| | |/| | | | | Month Day Year

INSTRUCTIONS: In the space below, please provide contact information for three close relatives or friends who do not live with you and are likely to know how to reach you over the next year. We will only contact these people if we are unable to contact you directly. Please complete all three boxes if possible.

1. CONTACT INFORMATION FOR FIRST RELATIVE OR FRIEND

NAME: Last

First

Middle

ADDRESS: Number and Street

Apt. No.

City

State

ZIP Code

How is this person related to you?

1 □ Mother

2 □ Father

3 □ Sister/Brother

4 □ Friend

5 □ Grandmother/Grandfather

6 □ Other (Specify)

Home: (__________) - ___________ - ___________ Area Code Number

Cell: (__________) - ___________ - ___________ Area Code Number

Work: (_________) - ___________ - _____________ Area Code Number

Email Address #1

Email Address #2:

Name of Employer?

2. CONTACT INFORMATION FOR SECOND RELATIVE OR FRIEND

NAME: Last

First

Middle

ADDRESS: Number and Street

Apt. No.

City

State

ZIP Code

How is this person related to you?

1 □ Mother

2 □ Father

3 □ Sister/Brother

4 □ Friend

5 □ Grandmother/Grandfather

6 □ Other (Specify)

Home: (__________) - ___________ - ___________ Area Code Number

Cell: (__________) - ___________ - ___________ Area Code Number

Work: (_________) - ___________ - _____________ Area Code Number

Email Address #1

Email Address #2:

Name of Employer?

3. CONTACT INFORMATION FOR THIRD RELATIVE OR FRIEND

NAME: Last

First

Middle

ADDRESS: Number and Street

Apt. No.

City

State

ZIP Code

How is this person related to you?

1 □ Mother

2 □ Father

3 □ Sister/Brother

4 □ Friend

5 □ Grandmother/Grandfather

6 □ Other (Specify)

Home: (__________) - ___________ - ___________ Area Code Number

Cell: (__________) - ___________ - ___________ Area Code Number

Work: (_________) - ___________ - _____________ Area Code Number

Email Address #1

Email Address #2:

Name of Employer?