Name of Business

First name of owner(s)

Last name of owner(s)

Phone *

Email *

Full Business Address *

City *

State *

Zip Code *

Website

Year business was established *

Demographic of owner applying:

Race/Ethnicity of owner applying

Products/Services offered

Number of full-time Employees

Number of part-time Employees

Last year's revenue.

Last year's annual revenue range.

General net income for last year.

Please list combined revenue for last 3 years.

Describe revenue trends:

Have you outlined 2-3 key leaders for your exit?

Outline any significant capital requirements of your business (describe uses and anticipated costs)

Do you foresee any upcoming changes in your business? This can include expansion, or new products/services offered. (expansion, new products offered?)

How did you hear about this opportunity for the program?

What is your motivation for considering employee ownership? Share your personal and business goals for employee ownership.

Anything else you’d like to share before you submit?

Equal Opportunity Employer Michigan Relay Center 711• Auxiliary Aids & Services Available to Individuals with Disabilities• Affiliated with the Michigan Department of Labor and Economic Opportunity, State of Michigan• Supported by the State of Michigan• A Proud Partner of the Employee Ownership Expansion Network • 1 (440) 567-1060.This program is funded with federal dollars.

Please submit any documents ( such as a prior feasibility study ) here.