Chicago MBOC Client Profile Form Contact Information Company Address City State Zip E mail How did you hear about the Chicago MBOC or CMBDC Demographic Information Gender of Majority Business Own by ltq93779


									Chicago MBOC

                                                            Client Profile Form
 Contact Information

Company                                                                    Name/Title
Address                                                                    Suite/Bldg #
City/State/Zip                                                             Telephone Number                                           Ext.
E-mail                                                                     Fax Number

How did you hear about the Chicago MBOC or CMBDC?

 Demographic Information

Gender of Majority Business Owner
     Male            Female          Male/Female
Ethnicity of Majority Business Ownership
       Black/African American        White/Caucasian             Latino           Asian and Pacific Islander       Native American, Eskimo and Aleut
       Multi-racial       Other
Is your company a certified Minority    Yes       No                       Is your company a certified Woman      Yes        No
Owned Enterprise (MBE)?                By which                            Owned Enterprise (WBE)?                By which
                                          agency                                                                  agency
Business Information

Date Established                                                   (FEIN)             -
                                                                   Federal Employer Identification Number
 What is your current business status?
    Pre-Venture           Start-up                                                     Established
                          (has generated revenue for 3 years or less)                  ( has generated revenue for greater than 3 years)

 What are your annual sales? How many people does your company employ?

                           2006 Actual               2007 Actual              2008 Projected            2009 Projected            2010 Projected

  Sales                    $                         $                        $                         $                         $

  Net Income               $                         $                        $                         $                         $

  FTE Employees*

 * FTE = Full-Time Equivalents (Indicate if your projections include Part-Time positions representing “Full
                                                                          Time                        “Full-Time Equivalents”)

 What are the dollar amounts of your three largest contracts?
 Largest Contract                                   2nd Largest Contract                                3rd Largest Contract

Which industry best describes your business?
    Service          Food Industry         Retail        Wholesale         Healthcare        Construction        Environmental         Technology
    Research/Development             Manufacturer/Producer         Non Profit           Other, please specify

Please describe your product or service

Please check all that apply to you and your business.
    Sole Proprietorship         Family-Owned             Partnership         Corporation            Limited Liability         Sub S Corporation

    Privately-Held              Publicly-Held
                                                                                                                Please continue on the other side ...
 Financing History

How is your business financed? Please check all that apply.
   Debt                                                               Equity
      Commercial Bank            Micro-lender                            Yourself, Friends, Family               Retained Earnings
      Personal Loan              Finance Company                         Angel/VC Investors                      Government Grants
      Credit Line                Insurance Company                       Public Stock                            Other

      Credit Card                Factoring Company                       Employees (Stock Ownership Plans)

If you have obtained debt financing, what amount have you received?

If you have obtained equity financing, what amount have you received?

 Chicago MBOC Assistance — Financing

If you are presently seeking financing, what amount do you need?

For what purpose are you seeking financing?
    Start up funds      Build, renovate or expand current facility      Operating (working capital)           New product development
    Purchase new technology/equipment              Research & Development               Other

Please indicate the financing services in which you are interested.
   Small business loan          Loan packaging            Challenge grant           Identification of potential equity investors

   Comprehensive business assessment (Review of                                     Financial analysis & creation of financial plan (includes
   business plan, organizational structure, competitive                             key ratios, break even analysis, assumptions)
   landscape & financial structure)
    Presentation coaching (strategies for investor & client                         Other

 Chicago MBOC Assistance — Sales and Marketing

Does your business have a written business plan                 Yes      No           Has it been updated in the past          Yes       No
If yes, please provide a copy when you return this                                    6-9 months?

Please indicate the sales and marketing services in which you are interested.

    Assistance creating or refining a sales and marketing                Market research & analysis to identify new customers

    Business plan review                                                 Sales analysis & planning (sales planning, strategy
                                                                         development, sales implementation)
    A competitive analysis of your industry                              Other

    Procurement assistance

Client Signature                                                                                       Date

For Office Use Only
 Chicago Minority                          Census Tract
 Development Council
                                                          LI                   MI                 EZ                EC

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