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2. 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.
6. Part A: Business Information
8. Business Owner Name
9. Email Address
11. Business Address
13. City
14. State
15. Zip Code
17. Phone Number - Business
18. Phone Number - Cell Phone
20. Are you already in business and being paid for your product or service?

    1. Yes
    2. No
21. If so, how many years in business?
23. Business Website
24. Business Facebook Page (if applicable)
26. Provide a brief description of your business. If not yet in business, summarize your new business idea.
30. Part B: Additional Information
32. How will Momentum 360 improve your financial management? What challenges are you looking to overcome?
34. Ethnicity
    -- Select One --AsianBlack/African AmericanHispanicNative AmericanPacific Islander/Native HawaiianWhiteOther
36. How did you hear about Momentum 360?
    -- Select One --City WebsiteFriend/ColleagueDurham TechPress ReleaseOther
40. Part C: Agreement and Signature
    Applicants must attend 6 weeks (once weekly) of a small business course held online via Zoom, so reliable access to a computer with Internet connection is required. Each class is 2 hours long and will be held on Thursday evenings 6:00 pm - 8:00 pm in Summer 2021. By submitting this form, I am agreeing that, if selected, I am able to attend 100% of these Thursday night classes.
42. Initials
    Type applicant initials.
43. Date
    Date
45. Receive an email copy of this form.

    1. Yes
    2. No
47. Email address
    This field is not part of the form submission.
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

* indicates a required field