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Dane County Small Business Awards 2012
Nominee Questionnaire
Your completed survey must be received No Later than April 27, 2012 to be considered.
Please download this questionnaire at http://sbdc.wisc.edu/DCSBA/questionnaire.doc and fill out
using Microsoft Word or compatible software.
Please Email your competed questionnaire as an attachment to: Neil Lerner at the UW-Madison
SBDC nslerner@wisc.edu and Cherrie Johnson at WBD Finance cjohnson@wbd.org .
Up to 10 company awards will be given. To qualify for this award your company must be:
A successful for-profit company at least three (3) years old.
An emerging business award will be considered for a 1 – 3 year old company. Applicants in this category
do not need to meet the minimum employee criteria.
Have a minimum of three (3) full-time equivalent employees, including yourself.
Have $20 million or less in annual sales.
We strive to recognize a mix of excellent small businesses that represent communities from around Dane County;
two categories include firms with less than $5 million in sales and $5-20 million in sales; minority-owned, women-
owned and emerging small firms are encouraged to apply.
For short answer questions, please add additional pages if needed. You must complete this questionnaire to be
considered for an award. Other enclosed material in place of any or all parts of this questionnaire will not be
considered.
Name of Person Completing Questionnaire:
Email and phone number please:
Date:
1. Please fill in the following:
Name of Owner, President, CEO:
Title:
Name of Company:
Address:
City / State / Zip:
Phone (if different than above):
Fax:
Email (if different than above):
Website:
2. Please check all that apply:
Woman-owned (at least 50% ownership and 50% daily management in the business)
Minority-owned (at least 50% ownership and 50% daily management in the business)
If you are a minority-owned firm, please specify your heritage: _________________
(African American, Asian, American Indian, Hispanic/Latino, other)
Emerging Business (1 – 3 years old. Applicants do not need to meet the minimum employee criteria.)
Your Business
3. Briefly describe your main business.
4. Describe any significant company accomplishments that you are especially proud of since the firm’s
inception. You can include how you are dealing with the current challenging economy if you wish.
5. How many years has your company been in business?
6. How many people do you employ, including yourself?
Current 2012
Full-time
Part-time
7. Please provide the following financial information. This information is confidential.
Total Sales Volume 2011
Less than $ 5,000,000
$ 5,000,001 -$20,000,000
8. Describe your company’s growth in revenues, profits and employees since the firm’s inception. Please be
as specific as possible.
Rewarding Work Place
9. What benefits does your company provide? Please check all of the following that apply:
Full-time Employees Part-time Employees
Health insurance
Paid vacation
Sick Leave
Dental insurance
Retirement plan / 401K
Professional development opportunities
Wellness/Fitness Club Program
Flexible work hours
Child care
Profit sharing or stock options
Other
Other things that you do that make your company a great place to work?
Community Contributions
10. Describe your contributions to your community.
How have you, your company and employees contributed to your community in order to make Dane County a better
place to live? Tell us about volunteer activities, donations or other in-kind activities that have benefited your
community. Please describe in regards to:
Your company’s contribution:
Your employees' contribution:
The Owner/Partner’s personal contribution:
11. Include any other information that you think would be pertinent.
We will notify you about the status of your nomination in May 2012. If you have any questions, please contact
Neil Lerner at 608-263-0221 or nslerner@wisc.edu. Thank you.
