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2. 
3. Momentum 360 Program Application
   Fall 2019
5. Instructions
   Please fill out this form as completely as possible, and sign and date the bottom of the form. Incomplete or invalid information will not be processed. The deadline to submit an application is October 1, 2019.
9. PART A: BUSINESS INFORMATION
11. Business Owner Name
12. Email Address
14. Business Address
16. City
17. State
18. Zip Code
20. Phone Number - Business
21. Phone Number - Cell Phone
23. Are you already in business and being paid for your product or service?

    1. Yes
    2. No
24. If so, how many years in business?
26. Business Website
27. Business Facebook Page (if applicable)
29. Provide a brief description of your business. If not yet in business, summarize your new business idea.
33. PART B: ADDITIONAL INFORMATION
35. How will Momentum 360 improve your business management. What challenges are you looking to overcome?
37. Is your annual household income below $60,000?

    1. Yes
    2. No
39. Ethnicity
    -- Select One --AsianBlack/African AmericanHispanicNative AmericanPacific Islander/Native HawaiianWhiteOther
41. How did you hear about Momentum 360?
    -- Select One --City WebsiteFriend/ColleagueDurham TechPress ReleaseOther
45. PART C: AGREEMENT AND SIGNATURE
    Applicants must attend 8 weeks (once weekly) of a small business course held at The Small Business Center at Durham Tech in downtown Durham. This is provided free of charge. Each class is 3 hours long, includes light dinner, and will be held on Tuesday evenings 6:30 pm - 9:00 pm in Fall 2019. The assignments are online so you need reliable access to a computer and can expect approximately 3 hours of homework each week. By submitting this form, I am agreeing that, if selected, I am able to attend 100% of these Tuesday night classes.
47. Initials
    Type applicant initials above.
Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit Submit and Print

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