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SHAEC/HCDC Registration Form
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SHAEC/HCDC Registration Form
SHAEC/HCDC Registration Form
southernhilltownsaec
2022-05-21T01:05:32-05:00
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Please check to register for a Sustainability class
Easy Organic Gardening: Saturday, June 25th, 6-7:30pm
Water Gardens and features: Saturday, July 23rd, 6-7:30pm
Heirloom Gardening: Saturday, August 27th, 6-7:30pm
Seasonal Change in the Garden September: Date/time TBD
Indoor Plants and Tropicals: October: Date/time TBD
Simple Bonsai: November: Date/time TBD
Would like more information about ...
Community Health Worker Pre-apprenticeship Program
Math– at your own pace Virtual class Tues/Thurs @ 3:30pm w/ Garrett Westcott
HiSet Writing
GED or HiSet
One-on-one assistance
Additional Notes
Today's Date
*
Town of Residence
*
Name
*
First
Last
Email
*
Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Preferred Phone
*
Home Phone
Work Phone
Please Check All That Apply
Male
Female
Disabled
Immigrant
Employed
60 yrs. or older
Under 25
Self employed
Veteran
Student
Retired
Single Parent Household
American Indian or Alaska Native
Asian
African American
Native Hawaiian or Other Pacific Islander
White
Hispanic or Latino
Household Size
*
1
2
3
4
5
6
7
8
Please choose the income that best fits your household of 1
$17,700
$29,450
$47,150
$47,151 +
Please choose the income that best fits your household of 2
$20,200
$33,650
$53,850
$53,851 +
Please choose the income that best fits your household of 3
$22,750
$37,850
$60,600
$60,600 +
Please choose the income that best fits your household of 4
$26,500
$42,050
$67,300
$67,301 +
Please choose the income that best fits your household of 5
$31,040
$45,450
$72,700
$72,701 +
Please choose the income that best fits your household of 6
$35,580
$48,800
$78,100
$78,101 +
Please choose the income that best fits your household of 7
$40,120
$52,150
$83,500
$83,501 +
Please choose the income that best fits your household of 8
$44,660
$55,550
$88,850
$88,851 +
How did you learn of SHAEC?
If you are a business owner please complete the next page and then submit. If not, continue to next page and then submit.
Next
Business Information
Business Name
Business Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Business Phone
Total Number of Employees (including owners)
Number of Full Time Employees
Number of Part Time Employees
What best describes your business status now?
Startup (business opened – sales/revenue for 3 months)
Stabilized (business operating/generating revenue)
Expanding (profitable/employing at least 1FTE)
Pre Startup (within 1 year of startup)
Prospective business owner (more than 1 year from startup)
What assistance are you seeking?
Exploring a business idea
Creating a business plan
Starting a business
Expanding your business
Marketing/advertising your business
Purchasing a business
Value-Added Farm Product
Financial management/planning
IT/Web support
Accounting assistance
Rental space
Seeking a loan
Food processing center/Food business
What best describes your current employment status?
Starting a business as result of unemployment.
Unemployed
Working full time
Working part time
In school or training program
Homemaker
Laid off
Self-employed
Seeking employment
Working more than one job
How did you hear about Hilltown CDC’s Small Business Development Program?
Comments
For security what is 6 + 7?
*
Message
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