Application for Program Participation

First Name: ● Middle Initial: Last Name: ●

SSN: ● Date of Birth: ● (MM/DD/YYYY)

You must be registered in Employ Florida at www.EmployFlorida.com
Employ Florida Log in Username: ●

Address: ● Email: ●

City: ● State: ● Zip: ●

Primary Phone Number: ● WorkHomeCell ●

Secondary Phone Number: WorkHomeCell

How did you hear about Start-Up Now? Broward College or Innovation Hub Office of Economic/Small Biz Development CareerSource Broward Facebook/Linked In/Twitter Greater Fort Lauderdale Alliance Hispanic Unity of Florida Inventors Society of South Florida Jim Moran Institute Global Entrepreneurship SCORE Small Business Development Center Urban League Other ●
If Other, specify:

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This program provides intensive training in order to start a business using a hands-on approach. It requires your dedication and commitment. The following is key information about the program :

• The program is open to anyone who is committed to starting their own business.
• You must be able to support yourself during the entire duration of the program (6 - 7 months).
• You can work during the program, but coursework out of classroom time will take 15 - 20 hrs./week.
• Not everyone who applies will be selected to participate.
• Not everyone who is accepted will progress through each step of this program.

This program provides intensive, hands-on training to start a business. The following is key information about the program:

• The program is open to anyone who is committed to starting their own business.
• You must be able to support yourself during the entire duration of the program (7 months).
• Work outside of the sessions will take 15 - 20 hrs./week.
• Not all who apply will be selected. Not all who are accepted will progress through each step of this program.
• You are committing to spend your money meeting specific milestones to launch your business.
• Businesses must be opened in South Florida.
• You must apply as a continuing education student at Broward College. (We will facilitate this.)
• You must apply as a credit-earning, non-degree seeking student at Broward College. (We will facilitate this.)
• All requested documentation must be provided.

Considering the above requirements, are you able to commit to this 7 month program? YesNo ●

How many people, including yourself, live in your household? ●

What is your status in the family? Parent in a one-parent family Parent in a two-parent family Spouse in two-person family Other family member I live by myself ●

How many children live in the home? 0 1 2 3 4 5 6 7 8 9+ ●

Were you laid off from your last job? YesNo ●
If so, when was your last date of employment? ● ● Please enter a valid date. (MM/DD/YYYY)

What was your last hourly wage? $ ●

Have you received unemployment compensation within the last 6 months? YesNo ●

Have you received public assistance within the last 6 months? YesNo ●

What is your total gross family income (before taxes & deductions)?
Please include income from all people living in the home    $.00 ●

Are you currently enrolled in CareerSource's WIOA program? YesNo ●

Have you ever been enrolled in other CareerSource Broward programs? YesNo ●
If so, list them:

Sex: MaleFemale ●

Citizenship/Legal Status: U.S. Citizen Lawfully permanent resident Other immigrant authorized to work in the U.S. Other ●

What is your primary language? English Spanish French Haitian Creole Portuguese Other ●

Are you currently in school, or participating in any kind of instruction or training?: YesNo ●

If you answered yes, what is it and where are you receiving the instruction? ●

What is your highest level of education? Less than a High School Diploma GED/High School Diploma Equivalent High School Diploma Some College, No Degree Vocational School Certificate Associate's Degree Bachelor's Degree Master's Degree Doctorate Degree Specialized Degree (e.g. MD, DDS) ●

Year diploma, degree, or certificate was earned; or, if less than a high school diploma, last year in school. ●

Field of study; if you selected "less than a high school diploma", "high school diploma/GED" or "some college, no degree" earlier, type NA in this field. ●

Other training, certifications, or licensures:

Have you served in the military? YesNo ●

Have you registered for Selective Service? YesNoN/A ●

Do you consider yourself as having a disability? YesNo ●

Are you an ex-offender? YesNo ●

Are you homeless? YesNo ●

What is your current employment status? Working full-time (32 or more hours/week) Working part-time 5-15 hours/week Working part-time 16-25 hours/week Working part-time 26-31 hours/week Not working Never worked Other ●
If Other, specify:

If you are not working or are underemployed, what are you doing now? Looking for work In school/training program Taking care of a family member Retired Other ●
If Other, specify:

What is your current job title, or if you are not working now, what was your last job title? ●

What type of business are you or were you last working in? Aerospace & Aviation Banking/Financial Services Construction Consulting Creative Economy & Film Education Government Hospitality Life Science/Biosciences Logistics & Transportation Manufacturing Medical/Healthcare Professional Services Retail/Wholesale Technology Other ●
If Other, specify:

Was your current/most recent job full-time or part-time? full-time (32 or more hours per week) part-time ●

How many years of management experience do you have? ●

Are you self-employed now? YesNo ●

Have you been self-employed in the past? YesNo ●

How long have you been, or were you self-employed? ●

How many hours per week are you engaging in or did you engage in self-employment? 32 or more hours per week Less than 32 hours per week ●

Including yourself, how many employees work(ed) in the business? ●

In what type of business are/were you self-employed? Aerospace & Aviation Banking/Financial Services Construction Consulting Creative Economy & Film Education Government Hospitality Life Science/Biosciences Logistics & Transportation Manufacturing Medical/Healthcare Professional Services Retail/Wholesale Technology Other ●
If Other, specify:

Do you have a business idea (product or service) that you are interested in bringing to market? YesNo ●

If so, at what stage are you? Just an idea Currently writing my business plan I have a mock up of the product I have a working prototype of the product Have been providing the service or selling the product for less than a year Other (please explain) ●
If Other, please explain:

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In fifty words or less, answer these questions:

1. What problem is your product or service solving?
2. How will you make money?
3. Is there an innovative aspect to your business idea?

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Email the following documentation to Douglas Sáenz at dsaenz@careersourcebroward.com

Checklist —

☑ Your resume

☑ Color copy of your DD-214 (if a veteran)

☑ Color copy of your proof of Selective Service Registration. Must be registered with the Selective Service System (if born male on or after Jan 1, 1960). Go to www.sss.gov, then click “Registration” then “Check Registration”.)

☑ Color copy of your signed Social Security card.

☑ U. S. citizens – color copies of:

• your driver’s license, AND
• U.S. issued passport OR birth certificate.

☑ Non-citizens – color copy of:

• your driver's license, AND
• resident card OR work permit authorization.

☑ Florida Residency - Refer to Section #2 on this linked document to see what documents are required prior to starting the program. Key points:

• Make sure all copies are color copies
• All documents must be dated, issued or filed at least twelve (12) months before the first day of the program
• Documents must not be expired
• Either two items from tier one OR one item from tier one and one item from tier two are required

☑ OFFICIAL college or high school transcripts. These are sent directly from the high school, college or university. Have these sent to:

• Electronically: whc-admissions@broward.edu
• Mail: Broward College Admissions, 111 E. Las Olas Blvd., Bldg. 33, Room 219, Fort Lauderdale, FL 33301

☑ Acknowledgement Form – Innovation Hub

☑ Personal Information and Emergency Contacts Form

☑ Signed Participation Agreement

☑ Audio/Video/Print Release Form

☑ Records Release/Consent Form

☑ FERPA Release Form (Under "This release/disclosure may be made to..." you must type in CareerSource Broward / Start-Up Now. Under "Types of Education Information to Release", you must check “Academic Grades”, “Academic Records” and “Registration”)

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