Black Wall Street AVL New Client Application

Your Primary Contact Information

Name*

First Last

Email*

Phone*

Do you want to receive text notifications?

Yes
No

Do you have a loan through Mountain BizWorks?*

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In SalesForce?

New Client Information

Home Address*

Street Address City State ZIP Code

County (Example- Buncombe)*

Gender*

Ethnicity*

Current Military Status*

Primary Language*

Date of Birth*

Are you the head of your household?*

Do you identify as a single parent?*

Do you want to learn more about new and cool opportunities for support?

Yes!
No, thanks.

Current Military Status*

How did you hear about us?*

Please check all that apply!

Scholarship Information

Would you like to apply for a Mountain BizWorks scholarship?*

Partnership Code

Please note that a Mountain BizWorks team member may still reach out about finalizing your scholarship details.

Scholarship Application

Mountain BizWorks and our funding partners strive to expand access to our services by offering financial-need based scholarships as current support allows. Please answer the following questions to the best of your ability and note these expectations of our scholarship awardees: 1) you'll need to provide documentation verifying your income level & a photo ID- see below; 2) you'll agree to participate in an annual impact survey. Your information will be kept strictly confidential by Mountain BizWorks and, if required, by our scholarship funding partner. Please contact us if you need any assistance in completing the application. Documents can be emailed to scholarship@mountainbizworks.org if you choose not to upload them at this time.

Total Annual Household Income*

Please enter the dollar amount of adjusted gross income as reported on your most recent tax return. If you share finances with a spouse and file separately, please report the combined income total.

Total # of people supported by this income including yourself.*

Hidden

Projected Total Household Income for this year

Additional Financial Situation Details

Please use this space to optionally provide any additional details on your current financial situation that may help clarify any of the answers above or otherwise help us consider your scholarship request.

Proof of Income & Identification*

Documentation is attached below
I'm emailing it to scholarship@mountainbizworks.org

Proof of income and identification is required to process your application. You may attach it below (fastest), email it to scholarship@mountainbizworks.org, or bring it by the office. Acceptable proof of income includes A) most recent tax filing (first page only), B) most recent W-2, C) 2 consecutive paystubs, or D) other documentation deemed sufficient by MBW staff to verify the income reported above.

Please note that we cannot review your application until we receive the required proof of income, photo ID, & Business EIN or SSN.*

Understood. I'll get them in ASAP.

File Upload for Proof of Income*

Drop files here or

Max. file size: 300 MB, Max. files: 4.

File Upload for Photo ID*

Drop files here or

Max. file size: 300 MB, Max. files: 4.

Business Status

Are you currently in business?*

Are you a current or aspiring farm enterprise?*

Farm Profile

We are pleased to be partners with the Appalachian Sustainable Agriculture Project and can provide reduced cost coaching to qualifying farms.

Is your farm Appalachian Grown™ certified?*

Yes, my farm is certified
Not yet

Active or in-progress certification may be required to received reduced cost services through our ASAP partnership.

Acres in Production*

Farming Status*

Business Profile

Business Name*

Include DBA if applicable. Enter "startup" if you don't have a business name yet.

Please provide a one-sentence description or "elevator-pitch" for your business. (max 250 chars.)*

Business Web Address

Business Phone

Year Started*

Example: 2017

Legal Status*

Tax ID / Federal EIN*

If you have a UEI #, please enter it here.

A Unique Entity Identifier (UEI) is a number issued by the System for Award Management (SAM) to identify businesses and other entities that do business with the federal government. The UEI has replaced the DUNS number as the authorized identifier for the federal government. It is free to obtain on Sam.gov

S.S. #*

Number of full time staff*

Full Time = 30 hrs/wk or more. Please include all paid positions including W-2 positions, owner positions and any contractor positions that are consistently supported.

Number of part time staff*

Part Time = less than 30 hrs/wk. Please include all paid positions including W-2 positions, owner positions and any contractor positions that are consistently supported.

Are you the sole owner of the business?*

Yes
No

Please list all owners of the business

Name	Title	Gender	Race	% Ownership

Business Mailing Address (if applicable)

Business mailing address is same as my home address

Business Mailing Address

Street Address City State ZIP Code

Business County (Example- Buncombe)*

Businesss Physical Address

Physical address is same as mailing address

Business Physical Address

Street Address City State ZIP Code

Hidden

Biz Mailing County (Don't Need)*

For the most recent full business year, what was the business' gross sales/revenues?*

(Please provide an estimate if the exact figure is unknown. Enter zero (0) if not yet in business.)

For the most recent business year, what were the business' profit/losses?*

(Please provide an estimate if the exact figure is unknown. Enter zero (0) if not yet in business.)

Startup Profile

Please provide a short (250 chars. max) description of the business concept or the opportunity you'd like help with.*

Coaching Goals & Topics of Interest

Please share with us what you hope to achieve with your business coach. Please use details that can help us find the best fit coach for you.*

Select the top 2 area(s) you would like to receive business coaching support.*

Business/Strategic Planning
Financials
Marketing: General
General Business Coaching
Human Resources
Innovation & Adaption
Non Profit / Social Enterprise Management
Operations

Is there additional information you'd like to share with us? For example your learning style, types of mentoring that works for you, etc. If you would like to request a specific coach, please do so here.

Certify & Submit

Certification of Accuracy*

I do hereby certify that all information given in this application is true and accurate to the best of my knowledge. I understand that Mountain BizCapital, Inc. dba Mountain BizWorks and/or its agent may rely on the accuracy thereof in acting on this application and that any fraudulent information may result in disqualification from the program. I give my permission for Mountain BizWorks and/ or its agent to make inquires as to my income and my employment. For subsidized coaching applicants only: I also give my permission for Mountain BizWorks to share my application information with City of Asheville and HUD officials while conducting official business.

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Email

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Application for new Black Wall Street Coaching Clients

Your Primary Contact Information

New Client Information

Scholarship Information

Scholarship Application

Business Status

Farm Profile

Business Profile

Startup Profile

Coaching Goals & Topics of Interest

Certify & Submit

Stay connected to the local community of entreprenuers with Mountain BizWorks.