StartZone

Application for Membership

Please fill out this application completely. Startzone membership is competitive and not every applicant will be accepted. StartZone staff will notify you of your application status within one week of the application date. All information provided on this application is strictly confidential. You may also apply by phone by calling 206.878.3710 ext. 5152 or in person at 23835 Pacific Highway South, Kent, WA 98032. Map & directions

* Indicates a required field.

Contact Information

First Name:* Last Name:*	Home Phone:
Address 1: Address 2:	Cell Phone:
City:* State:* Zip:	Business Phone:
Email:	* Enter at least one phone number.

Best way to contact:
Email
Home phone
Cell phone
Business phone

Best time to contact:
Morning
Afternoon
Evening

Demographics

Ethnicity:*

Asian
Black or African American
Hispanic
Native American or Alaska Native
Native Hawaiian or Pacific Islander
Caucasian

Education:

High School
College
Graduate School

Gender:*

Male
Female

Birth Date
(MM/DD/YYYY)

Do you consider yourself a person with a disability? If YES, please describe any accommodations you need in order to participate in StartZone (for example: sign language, interpreter, wheelchair access, Braille translation).	Yes No
Are you currently enrolled as a student at Highline Community College?	Yes No
Are you a first-generation immigrant? If YES, provide information about your native country and language.	Yes No I am from I am most comfortable speaking
What was your total household income last year (please estimate)?	$
How many people share income and expenses in your household?	(including children) (number of children)
What experiences (in the U.S. or in your native country) do you have that will help you start or grow your business? (Example: English classes, worked in a business, family member owned business, work experience, etc.)

Business Information

Are you currently in business?

Yes No

Why do you want to start your business?
What type of business would you like to start?	When would you like to open your business?
Would you like your business to be your primary source of income? Yes No

What is the name of your business?	When did you start your business?
How does your business make money?
Do you conduct business online?	Yes No
How many people do you employ?	Full-time: Part-time:
What were your sales for the most recent year?	$
What were your profits/losses for the most recent year?	$
If you currently own any other business or have any other sources of income, please describe:

Business Goals

What business goals do you hope to accomplish at StartZone?
Start my new business
Hire employees
Obtain a loan to start or grow my business
Increase sales to $
Other (please describe below)

Referral Source

How did you hear about StartZone?

Bank
Business Owner
Television/Radio
Newspaper/Magazine
Internet

Chamber of Commerce
Educational Institution
Local Economic Development Council
Word of Mouth

Church/Mosque
Community Center
ESL Program
Other (please specify):

2400 S. 240th St
Des Moines, WA 98198
(206) 878-3710
TTY/TDD (206) 870-4853

Page last updated: September 13 2009

This web site was developed by and is maintained by the Small Business Development Center. If you have questions or concerns about the content, please contact us.

Highline Community College Web Coordinator: webmaster@highline.edu

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