Form Center

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 Name*
12. Are you already in business and being paid for your product or service?*

    1. Yes
    2. No
14. If so, how many years in business?
15. Is the business registered with the NC Secretary of State?*

    1. Yes
    2. No
17. If so, what is the registration status (LLC, Corporation, etc.)?
19. Business Address*

    For home-based businesses, enter the home address

21. City*
22. State*
23. Zip Code*
25. Phone Number*

    Enter the best phone number to reach the applicant

26. Business Website (if applicable)
28. Business Social Media (if applicable)
30. Are you a certified Minority- or Woman-Owned Business Enterprise (MWBE)?*

    1. Yes
    2. No
31. How many employees do you have (including yourself)?*

    1. 5 or fewer
    2. 6-10
    3. 10-20
    4. 20+
33. Provide a brief description of your business. If not yet in business, summarize your new business idea.*
35. How has COVID-19 impacted your business?*
39. Part B: Financial Information

    This information will be kept completely confidential, and will only be used to determine eligibility.

41. Have you received funding for your business within the past year?*

    1. Yes
    2. No
42. If yes, please select the type(s) of funding you received

    1. Durham Opportunity Loan Fund/Recovery Fund
    2. SBA EIDL
    3. SBA PPP
    4. Corporate Grants
    5. HUB Office Funding
    6. Other
44. If "Other", please specify
45. What was the business' annual revenue in 2021?*

    1. Less than $20,000
    2. $20,000 - $35,000
    3. $35,000 - $50,000
    4. $50,000 - $75,000
    5. $75,000 - $95,000
    6. More than $95,000
47. What was the business' annual net profit in 2021?*

    1. Less than $5,000
    2. $5,000 - $10,000
    3. $10,000 - $20,000
    4. $20,000 - $35,000
    5. $35,000 - $50,000
    6. More than $50,000
    7. Not sure
48. How many people live in your household?*

    1. 1
    2. 2
    3. 3
    4. 4
    5. 5
    6. 6
    7. 7
    8. 8+
50. What was your annual household income for the 2021 tax year?*

    1. Less than $20,100
    2. $20,100 - $35,000
    3. $35,000 - $55,000
    4. $55,000 - $75,000
    5. $75,000 - $95,500
    6. More than $95,500
51. Supporting Tax Documents*

    Please upload your 2021 tax return to confirm your annual income.

53. Do you pay yourself?*

    1. Yes
    2. No
54. Do you currently use an accounting system for maintaining your business financial records?*

    1. Yes
    2. No
56. If yes, please select the type(s) of accounting system

    1. Spreadsheet
    2. QuickBooks
    3. Wave
    4. FreshBooks
    5. Xero
    6. Other
57. If other, please specify
61. Part C: Additional Information
63. Ethnicity*
    -- Select One --AsianBlack/African AmericanHispanic or LatinoNative AmericanPacific Islander/Native HawaiianWhiteMultiracialOtherPrefer not to disclose
64. How did you hear about Momentum 360?*
    -- Select One --City WebsiteSocial MediaFriend/ColleagueDurham TechPress ReleaseOther
66. Are you related by blood or marriage to anyone who works for the City of Durham?*

    1. Yes
    2. No
67. If yes, please list the department that they work for within the City.
69. How will Momentum Financial Academy improve your financial management? What challenges are you looking to overcome?
71. Is there anything else you would like us to know?
75. Part D: Agreement and Signature

    Applicants must attend 4 weeks (twice 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 Tuesday and Thursday mornings from 8am - 10am. By submitting this form, I am agreeing that, if selected, I am able to attend 100% of these Tuesday and Thursday classes.

77. Initials*

    Type applicant initials.

78. Date*
    Date
80. Receive an email copy of this form.

    1. Yes
    2. No
82. Email address
    This field is not part of the form submission.
Leave This Blank:


84. 1. Receive an email copy of this form.
85. Email address

    This field is not part of the form submission.

86. Submit

* indicates a required field