EA application - ChamberECT

Contact Information

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Voluntary Self Identification

Which gender do you identify with the most? *

Female
Male
Not listed
I prefer not to answer

Which of the following best describes you? *

Are you a protected veteran? *

I belong to the following protected veteran classifications: Active wartime or campaign badge veteran; Armed forces service medal veteran; disabled veteran; recently separated veteran
I am a protected veteran but choose not to select my classification
I am not a protected veteran
I prefer not to answer

Do you plan on having team members in addition to yourself participate in this program? *

Yes
No

Add Additional Team Members Names and Emails

Example: Jane Doe, jane@gmail.com ; John Doe, john@gmail.com

Venture

Industry of Your Business Idea *

Other:

Please briefly describe your idea. *

Please write approximately 1 paragraph.

Describe any progress you have made. You may also include any educational, work, or life experience you may have related to your idea. If you just have an idea, that is OK. *

Please write approximately 1 paragraph.

Why would you like to participate in the Chamber of Commerce of Eastern Connecticut Entrepreneur Academy? *

Please write approximately 1 paragraphs.

How did you hear about this program? *

From what other source did you hear about this program?

Do you have any other information you would like to share? (ex. website links, social media, news articles)