Operated by PACE
Entrepreneur
Service Agreement
Instructions
Please fill out the application completely.
If you are not yet in business but seeking information to establish a business, please complete the ‘Prestartup/Entrepreneur’ section.
Please note that demographic information is collected for the purpose of documenting services provided under the auspices of the LA BusinessSource Center and is used to provide relevant resources (i.e. minority/women-owned funding opportunities, etc.). All information will be kept confidential.
If you are completing this application electronically: click into each line or box to fill in your answers and leave the signature line blank.
Application Checklist
Please:
Fill out all areas of the application which apply to you.
L.A. RESIDENTS OR THOSE OPERATING A BUSINESS IN L.A.: To verify your residence, please return your application with:
- A copy of your California identification/driver’s license
- If the address on your ID is not your current address, please attach a copy of a utility bill or other semi-formal documentation (i.e. notice from work, school or the government).
- If you are operating a business, include a copy of all business registration documents you hold for your business (i.e. business license, DBA, articles of incorporation, etc.)
If you have any questions, please visit the Frequently Asked Questions on our website at (213) 353-9400 or email Thank you for your interest in our training and/or business counseling services.
Operated by PACE
Intake Application
Client InformationPlease complete all information on the application legibly; put N/A on items that do not apply.
Name: / Suffix:Address: / City: / Zip:
Primary Phone: / Secondary Phone:
Email:
Demographic Information
Date of Birth: / Gender: / Female / Male
Ethnic Group
American Indian/Alaskan native / White (not Hispanic)Asian/Pacific Islander / Two or More Races
Black (not Hispanic) / Other
Hispanic
Educational Level (please check highest level completed
Less than High School / VocationalHigh School Diploma/GED / Bachelor Degree
Some College / Graduate Degree
Associate Degree / Other:______
Employment Status (please check the option that best applies)
Full Time Self-Employed / Part Time EmployedFull Time Employed / Seasonal Unemployment
Part Time Self-Employed / Unemployed less than 6 months
Unemployed more than 6 months / Other:______
Certification of Low to Moderate Income Status.Please check one of the following boxes:
My household’s yearly income is less than or equal to the income shown below for my family size.My household’s yearly income is more than the income shown below for my family size.
Please circle the family size that applies to you.
Family Size / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8Family Income / $46,650 / $52,200 / $58,700 / $65,200 / $70,450 / $75,650 / $80,850 / $86,100
Number in Your Household / Annual Income in 2015:
Business Information
Prestartup-Entrepreneur: If you have not started your business, complete this section.
Proposed Business Name:Type of business (product or service):
Proposed start date: / Business Partner?
Planned business location: / Home-based / Office/storefront / Online
Please describe any previous experience in the business you wishto start or relevant management/work experience.
Are you in need of assistance, if yes, please check the specific areas needed:
Access to Capita/Loan Packaging / Counseling / Business PlanMarketing / HR/Employee Hiring / Downsizing
Business Course/Workshop / Procurement / Other
List other ______
I certify that all my answers above are true and correct to the best of my knowledge. I also agree that by accepting to receive assistance from the BusinessSoure Center I will cooperate and provide the BusinessSource staff with all requested information and documents to verify the outcomes reported in compliance with CFR 570.506(b)(5) and (6) listed below.
Signature: / Business Owner / Date:Referral Information
How did you hear about this program?
Friend / Newspaper (specify)Online (specify) / WorkSource Center (specify)
ETP Alumni / Other (specify)
Action Plan
Based on the needs assessment results, these are the activities that we have determined to be the most appropriate to be carried out:
Activity / Planned Outcome (include details)Access to Capital/Loan Packaging / (i.e. $5,000 KIVA Zip loan)
Signature: / BSC Counselor / Date:
Signature: / BSC Director / Date:
Please return the application via postal mail, fax, or email to:
LA BusinessSource – Central West
1055 Wilshire Blvd., Ste. 900B
Los Angeles, CA 90017
CFR 570.506(b)(5) and (6)
(5) For each activity determined to benefit low and moderate income personsbased on the creation of jobs, the recipient shall provide the documentationdescribed in either paragraph
(b)(5)(i) or (ii) of this section.(i) Where the recipient chooses to document that at least 51 percent of the jobs will be available to low and moderate income persons, documentation for each assisted business shall include:
(A) A copy of a written agreement containing:
(1) A commitment by the business that it will make at least 51 percent of
the jobs available to low and moderate income persons and will provide training
for any of those jobs requiring special skills or education;
(2) A listing by job title of the permanent jobs to be created indicating which jobs will be available to low and moderate income persons, which jobs require special skills or education, and which jobs are part-time, if any; and
(3) A description of actions to be taken by the recipient and business to ensure that low and moderate income persons receive first consideration for those jobs; and
(B) A listing by job title of the permanent jobs filled, and which jobs of
those were available to low and moderate income persons, and a description
of how first consideration was given to such persons for those jobs. The description shall include what hiring process was used; which low and moderate income persons were interviewed for a particular job; and which low and moderate income persons were hired.
(ii) Where the recipient chooses to document that at least 51 percent of the jobs will be held by low and moderate income persons, documentation for each assisted business shall include:
(A) A copy of a written agreement containing:
(1) A commitment by the business that at least 51 percent of the jobs, on a full-time equivalent basis, will be held by low and moderate income persons; and
(2) A listing by job title of the permanent jobs to be created, identifying
which are part-time, if any;
(B) A listing by job title of the permanent jobs filled and which jobs were initially held by low and moderate income persons; and
(C) For each such low and moderate income person hired, the size and annual income of the person’s family prior to the person being hired for the job.
(6) For each activity determined to benefit low and moderate income persons based on the retention of jobs:
(i) Evidence that in the absence of CDBG assistance jobs would be lost;
(ii) For each business assisted, a listing by job title of permanent jobs retained, indicating which of those jobs are part-time and (where it is known) which are held by low and moderate income persons at the time the CDBG assistance is provided. Where applicable, identification of any of the retained jobs (other than those known to be held by low and moderate income persons) which are projected to become available to low and moderate income persons through job turnover within two years of the time CDBG assistance is provided. Information upon which the job turnover projections were based shall also be included in the record; (iii) For each retained job claimed to be held by a low and moderate income person, information on the size and annual income of the person’s family;
(iv) For jobs claimed to be available to low and moderate income persons based on job turnover, a description covering the items required for ‘‘available to’’ jobs in paragraph (b)(5) of this section; and
(v) Where jobs were claimed to be available to low and moderate income persons through turnover, a listing of each job which has turned over to date, indicating which of those jobs were either taken by, or available to, low and moderate income persons. For jobs made available, a description of how first consideration was given to such persons for those jobs shall also be included in the record.
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