Intake Form First Name*Last Name*Email* Cell Phone*Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Are you considered a minority?*YesNoAge*Ethnicity*Hispanic or LatinoAsianAfrican American or BlackAmerican Indian or Alaskan NativeNative Hawaiian or Pacific IslanderWhite or CaucasianAre you a veteran?*YesNoAre you a student?*YesNoWhat is the name of your school?What are you annual income?How did you hear about us?*CIELO EventFlyer/AdStopping bySocial MediaWebsiteWord of MouthWhat is your education level?*No High School DiplomaHigh School/GEDSome CollegeUndergraduate DegreeGraduate DegreeWhat industry are you in?*Accommodation and Food ServicesArts, Entertainment, and RecreationEnergy, Oil and Gas ExtractionFinance and InsuranceAgriculture, Forestry, Fishing and HuntingEducational ServicesHealth Care and Social AssistanceManufacturingReal Estate and LeasingServicesTechnologyTransportation and ConstructionAre you a start up business?*This means you have dabbled in a business idea, but not done much about it, or you have done a few things here and there, but not really formalized it.YesNoName of your company*What are you annual revenues?Revenues for calendar or fiscal year. If you are just starting, revenues up to date (estimate).How many employees do you have? Include yourself only if you have started the company.Describe in your own words what assistance you need.*Are there any other areas we can help you in?*Marketing/Business DevelopmentFinancial StatementsLoans or FinancingTaxes-BookkeepingLegal IssuesBranding-Business ConceptStartupManagementYour signature authorization: type first, middle and last name*Your signature authorization: I request business-counseling service from CIELO. I agree to cooperate should I be selected to participate in surveys designed to evaluate CIELO services. I understand that any information disclosed will be held in strict confidence. I authorize CIELO to furnish relevant information to the assigned management counselor(s). I waive all claims against CIELO personnel, and that of its Resource Partners and host organizations, arising from this assistance. Please provide your full name (First, Middle, Last) indicating your acceptance to the terms shown above.PhoneThis field is for validation purposes and should be left unchanged.