Name *

First Name

Last Name

Phone

(###)

###

####

Is your annual revinue under $500,000?

Yes

No

Do you have under $200,000 in assets?

Yes

No

Does your business or organization fit into any of the following categories?

(Check all that apply)

Veteran-owned

Located in Western Wisconsin or Chisago and Washington Counties in Minnesota

Agriculture or farm-related

Nonprofit

Musician or band

Comedian

Small business (other)

If selected, are you able to pay the $1,000 fee (half upfront) and your hosting costs?

Yes

No

Are you willing to collaborate and provide input during the design and development process?

Yes

No