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Civic Inclusion Challenge Intake Form

2. Basic Information

4. First Name*

6. Last Name*

8. Phone Number*

10. Are you a City of Buffalo resident?*

    1. Yes
    2. No

12. Home Address*

14. Business Information

16. DBA or Entity Name*

18. Year of Incorporation*

20. Ownership in the Company*

22. Business Address*

24. Certified M/WBE*

    1. Yes
    2. No

26. Is it in NYS?*

    1. Yes
    2. No

28. Is it in City of Buffalo*

    1. Yes
    2. No

30. Describe your Business in a few sentences*

32. What industry is your business in?*

34. What specific Services or Products does your company offer?*

36. Who is your target audience?*

38. List of Social Media Handles and Websites*

40. Financial Information

42. How much Income has your business made in the last 6 months?*

    1. $0 - $49,999
    2. $50,000 - $99,999
    3. $100,000 +

44. How much Income did your business make in 2019?*

    1. $0 - $49,999
    2. $50,000 - $99,999
    3. $100,000 +

Leave This Blank:


45. 1. Receive an email copy of this form.
46. Email address

    This field is not part of the form submission.

47. Submit

* indicates a required field