Registration Form

Start Date January 29, 2015. Every Thursday 5:30 to 9:00 p.m.*

Clay Center Medical Center: Hospital Education Room

*unless otherwise noted

Submit registration to:

Wendy Veatch | Wichita State University - Center for Entrepreneurship

1845 Fairmount Wichita, KS 67260-0147 | Call: 316-978-5219 | Fax: 316-978-3687

or

Lori Huber |Call: 785-632-5974 |

Please complete the following information:

First Name / Last Name
Business Name (if applicable)
Mailing Address / City / State / Zip
( ) / ( )
Primary Phone (daytime) / Cell Phone
Email Address
Payment Information
Please select your method of payment below. If you are paying with cash or check, please remit payment to:
Center for Entrepreneurship
Campus box 147
Wichita State University
1845 Fairmount St
Wichita KS 67208-9988
Attn: Wendy Veatch
☐ Cash / ☐Check / ☐ Credit Card / To pay with credit card please go to:
Billing Name / Billing Address
City / State / Zip

Please fill out a separate application for each participant. Make a copy if necessary.

1. Please provide a detailed description of your proposed or existing business and your target market.

Growing Rural Businesses – Clay County / Spring 2015 / 1

2. Position in industry (example: manufacturer, distributor, wholesaler, retailer).

3. Intended customers (who will pay for your product/service).

4. Who will make or supply your product or service (e.g., subcontractors, in-house/home based contractors).

5. How many years of experience have you had in the field in which you plan to start or have already started your business:

☐ / None / ☐ / 1-5 years
☐ / Less than 1 year / ☐ / 5 + years

6. How many years of experience have you had as a manager in a company you did not own:

☐ / None / ☐ / 1-5 years
☐ / Less than 1 year / ☐ / 5 + years

7. How many years of experience have you had managing your own business full-time:

☐ / None / ☐ / 1-5 years
☐ / Less than 1 year / ☐ / 5 + years

8. How many employees do you have or are a part of the company you represent:

☐ / None / ☐ / 5 to 10
☐ / 1 to 5 / ☐ / 10 +

8. How did you hear about us?

9. Why do you want to participate in the Growing Rural Businesses program?

Growing Rural Businesses – Clay County / Spring 2015 / 1