Workshop No.:N/A
Title:
or Subject

Start Date(--/--/--):

End Date(--/--/--):

Training City:

Syracuse NY

Name:

Prefix: (none) Mr. Ms. other: other:

First - Mid -                                            Last
-

Business Name:
    (If Any)

Address 1:
Home or Business Address

Address 2:
Alternate Address (If Any)

City: State: ZIP:

Home/cellular phone1: ()- Work/cellular phone2: ()-

Fax: ()- Web Site: Email Address:

I am:   (please check all that apply):

1. Business Owner 2. SCORE Client

3. In International Trade 4. SBA Client

5. Choose Not to Respond

Race: (checkmark one or more)

1. Native American
or Alaskan Native

2. Asian American

3. Black or African American

4. Native Hawaiian or other
Pacific Islander

5. White

Choose Not to Respond

Ethnicity:

0. Hispanic Origin 1. Not of Hispanic Origin 2. Choose Not to Respond

Gender:

1. Male 2. Female Choose Not to Respond

Do you consider yourself a person with a disability?

0. No 1. Yes 2. Choose Not to Respond

Veteran Status:

1. Veteran 2. Service Connected Disabled Veteran 3. Disabled Veteran 4. Non-Veteran 5. Choose Not to Respond

How did you learn of this workshop?

1. Word of Mouth

2. Bank

3. Newspaper

4. Chamber of Commerce

5. Internet

6. Radio

7. Television

8. Magazine

9. SBA

10. Choose Not to Respond

11. Other: