Let Us Help You

Carolina Small Business offers a variety of financing, counseling, and technical assistance services to aspiring and current entrepreneurs. After you complete the form, our team of experts will assess your submission and reach out to see how we can best help. This form will take about 10 minutes to complete.

NOTE: Please be advised that completing this form will supply preliminary details to assist your Business Solutions Officer in conducting a business assessment. It's important to note that this form is not a loan application.

Have you been in contact with a staff member from Carolina Small Business?

YesNo

Staff Member Name: Please select their name below. If the name of the staff member you've been in touch with is not listed below, just leave this field blank.

UserId

BSO Email

How did you hear about us?

Who may we thank for your referral to our organization?

Please indicate the specific person (if applicable)

Institution Name

Institution Name Other

About You

First Name

Last Name

Title/Position:

Phone Number

Email

Date of Birth

Home Address

Home City

Home Zip Code (5 digits)

Home State

County

Home out of state County

Demographic Information

We request that you provide the below demographic data to be in compliance with federal regulations. In addition, organizations which provide grant funding to us require that we ask some demographic questions not required by law. You must answer each question, but you may select "Decline to State" for any question. Federal law forbids discrimination on the basis of the below information, including whether you choose to furnish it. If you choose to not furnish this information, federal regulations require that we note gender, race, and ethnicity on the basis of visual observation or surname.

Gender

Race

Ethnicity

Veteran Status

Do you identify with one or more of the orientations within the LGBTQ+ community?

Do you wish to disclose a disability, defined as a physical or mental impairment that substantially limits one or more daily life activities?

Do you currently have a bank or credit union account?

Do you rent or own your home ?

How much is that monthly expense?

Year of Tax Return (AGI Year)

"Enter the year from the tax return you used to report your adjusted gross income (YYYY)

Household Size

Include yourself, your spouse (if applicable), and any dependents listed on your most recent tax return.

Adjusted Gross Income (AGI)

Enter the total adjusted gross income for your household from your most recent federal tax return.

Gross income includes wages, dividends, capital gains, business income, retirement distributions, and other income.

Adjustments are allowed AGI deductions including student loan interest, contributions to certain retirement accounts, alimony payments, and educator expenses.

Enter Adjusted Gross Income (AGI)

You reported $0 or negative income. Is this correct? If not, please enter your correct income below

Final AGI

What is your estimate of your personal credit score? If you are unsure, we recommend getting a score from a free service like Credit Karma.

Are you participating in the NC Minority Business Development Association? Please select Yes, No, or I don’t know

YesNoI don't know Tracks whether you are participating in the NC Minority Business Development Association.

File Uploads

The following documents can help us more quickly provide the services you need. If you don't have a requested document, you can skip the question.

Please upload your most recent business plan, if you have one:

Please provide your small business's most recent annual financial statement:

Request for Services Submission

Signature required. Please read the below statements carefully. After you are done, sign on the next page with your mouse (if on a computer) or with your finger (if on a tablet or cell phone). By signing, you indicate you have read/agreed to the below and that all information you have provided is true and accurate to the best of your knowledge.

Client Agreement

By submitting this form I am requesting business services from Carolina Small Business Development Fund (CSBDF) or one of its constituent programs. Some offices and programs of CSBDF are SBA Resource Partners, including the Western Women's Business Center (WWBC). If I receive services from the WWBC as a SBA Resource Partner, I agree to:

Cooperate should I be selected to participate in surveys designed to evaluate SBA services.

Allow my contact information to be released for purposes of SBA surveys and informational mailings regarding SBA products and services.

Authorize the release of information to the businesss services counselor(s) that will help with my request.

Waive all claims against CSBDF and the WWBC that may arise from receiving assistance.

Our Commitment

I understand that the CSBDF employees working on my request have agreed to: (1) not recommend goods or services from sources in which he/she has an interest, and (2) not accept fees or commissions developing from this counseling relationship.

Use of Information

I understand that the information I am submitting is subject to CSBDF's data privacy policy and any information disclosed will be held in strict confidence. Neither CSBDF nor its partners will provide your personal information to commercial entities without your explicit consent. I understand the information collected through is form is to help continuing improvement of business counseling programs, to ensure effective oversight and management of entrepreneurial development programs and grants, and to meet government reporting requirements.