BUSINESS RESOURCE CENTER ASSISTANCE REQUEST
How did you hear about Quincy 2000:
Your Name: Today's date:
Residence Address:
Home Tel#: Business tel#:
Do you own a business: yes no    How long have you been in business?
Business name:
Business address:
Briefly describe what your business does, or will do:
What type of assistance do you need? Please check all that apply.
Business planning Personnel Manufacturing
Start-up financing Proposal writing Financial record keeping
Marketing Inventory purchases Equipment purchases
Store layout/window display Other
The following information is required by HUD and will remain confidential.
Number of family members living in your household including yourself.
Check below your total household income during the last year.
$46,300 or less $59,551 - $66,150 $76,751 - $82,050
$46,301 - $52,950 $66,151 - $71,450 $82,051 - $87,350
$52,951 - $59,550 $71,451 - $76,750 Above $87,350
Check if you are a Female Head of Household
Please check any and all that apply to you.
White Hispanic Black/African American
Asian American Indian/
      Alaskan Native		 Native Hawaiian/
      Other Pacific Islander
American Indian/
      Alaskan Native & White		 Asian & White Black/African American & White

American Indian/
      Alaskan Native & Black/African American

Other Multi-racial