General Intake Form
gitaswastipr@gmail.com Switch account
* Indicates required question
Business Ownership
The following data is being collect for clients who have a currently-registered business. This
data is being collected for informational purposes only and to help PGC identify appropriate
services to support your business growth and comply with reporting requirements from
PGC funders. See our privacy policy for more information about how we use and protect this
data.
Are you the business owner? *
Yes
No
Name of Business *
Your answer
Are you the primary decision-maker for the company? *
Yes
No
Are you committed to remaining and operating in Hawaii long-term? *
Yes
No
Are you committed to job creation for low-income adults? *
Yes
No
How many owners of the business besides yourself? *
0 1 2 3 4 5
0 (me only) 5+ business owners
What percentage of your business/non-profit is female owned? *
Choose
What percentage of your business/non-profit is owned by a Veteran? *
Choose
Business registration date (if business is not registered please enter the *
date: 01/01/0101)
Date
dd/mm/yyyy
Type of business *
Food Services
Manufacturing
Information Technology
Construction
Retail Dealer
Finance/Insurance
Utilities
Wholesale Trade
Educational Services
Real Estate & Rental/Leasing
Waste Management & Cleaning Services
Health Care & Social Assistance
Arts, Entertainment & Recreation
Transportation & Warehousing
Professional, Scientific & Technical Services
Private Consulting
Agriculture, Forestry, Fishing & Hunting
Administrative & Support
Other:
Business Registration Type *
Choose
Is your business registration currently active and up-to-date? *
Yes
No
Tax Payer Identification Number FEIN # (if available)
Your answer
General Excise Tax Number (if available)
Your answer
State Tax ID # (if any)
Your answer
Do you have any of the following for your business? (Check all that apply)
Workers Comp Insurance
General Business Liability Insurance
Hawaii Compliance Express Certification
Auto Insurance (for business vehicles only)
Food Handlers Education Certificate
Temporary Food Establishment Permit
Annual Food Permit
Food Safety Liscence
Peddler's Permit
Pesticide License
Organic Certification
Additional Insurance not listed:
Not Insured or Underinsured
Other:
Business Street Address (if applicable)
Your answer
Do you conduct business online? *
Yes
No
Business Website (if applicable)
Your answer
Business Facebook Name (if applicable)
Your answer
Business Instagram Name (if applicable)
Your answer
Business Twitter Name (if applicable)
Your answer
Other Social Media links (if applicable)
Your answer
Are you employed outside of your business? *
Yes
No
If yes, is your employment full time or part time?
Full time (more than 20 hours per week)
Part time (less than 20 hours per week)
How Many current part time (Less than 20 Hours per week) and full time *
(More than 20 Hours per week) employees (including yourself) do you
have?
More
0 1 2 3 4 5
than 5
Part Time
Full Time
Does your company have any of the following certifications (tick ALL that *
apply):
Certified SDB (Small Disadvantaged Business)
SBA 8(a)
None
Other:
What was your company revenue from the last 12 months? *
Your answer
What is your company's average monthly revenue? *
Your answer
What is your company's cost of goods from the last 12 months? *
Your answer
What is your company's other expenses (outside of cost of goods) from *
the last 12 months?
Your answer
What is your company's average monthly profit (revenue - expenses)? *
Your answer
Have you ever received a grant, loan, or equity investment in your *
business to date?
Yes
No
Are you interested in a loan or investment in your company to grow, *
expand, etc?
Yes
No
Would you like assistance to create or improve your business, financial, *
and/or marketing & sales plan?
Need Haven't
Yes No Completed Other NA
Assistance Started
Business
Plan
Financial
Plan
Marketing
& Sales
Plan
To formally enroll you in PGC's programs, you will be required to submit *
documentation which should match the information provided here. Can
you certify the information above is correct?
Choose
Back Next Page 4 of 5 Clear form
Never submit passwords through Google Forms.
This form was created inside of PACIFIC GATEWAY CENTER. Report Abuse
Forms
