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Part #1: BASIC INFORMATION

Status *

Type of Client *

Chapter

Last Name *

First Name *

Middle

E-mail Address *

Phone *

Fax

Street

Additional

Zip code *

City

State

Part #2: DEMOGRAPHICS

Race

Ethnicity

Gender

Age *

Income

Military

Military Rank *

Education

Do you consider yourself a person with a disability? *

Yes

No

Choose Not to Respond

What prompted you to contact us? *

Business Owner

Chamber of Commerce

Choose Not to Respond

Educational Institution

Internet

Lender

Local Economic Development Official

Magazine

Newspapers

Other

Other Client

SBA District

SBA Website

Television/Radio

Word of Mouth

Is your business already established?

No

Yes

Business Name

Type of Business

Female Ownership

Male Ownership

Month and Year Business Started

Busyear

Total Number of Employees

Do you conduct business online? *

Yes

No

Choose Not to Respond

Are you a home based business?

Yes

No

Are you 8(a) certified?

Yes

No

Gross Revenues / Sales $

Profits / Losses $

LegalEntity

What is the nature of the mentoring you are seeking?

If you chose other, please describe the specific assistance requested.

messageSCORE Association

Sponsors

Byline Bank - sponsor

FGMK

Abt-Electronics

Abt-Electronics

Abt Electronics, Inc.

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neuberger-berman-squarelogo-1

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Logo_evanston Subaru_176x103

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NG_rgb_176x176-1

KirklandEllisLLP-1

mb financial bank

mb financial bank

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HLM_logo_hi-res.eps

crains

wintrust

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Mentoring
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SCORE Chicago
500 W. Madison, Suite 1150, Chicago, IL 60661

Phone:
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Fax:
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info@scorechicago.org

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