Owner Name *

First Name

Last Name

Phone Number *

(###)

###

####

Is your business based in Alaska? *

Yes

No

Are all owners Alaska residents? *

Yes

No

Is your business currently operating? *

Yes

No

Do you have all required licenses, permits, etc.? *

Yes

No

Do you have any open collections or past due child support?

Yes

No

Are you or have been a resident with Cook Inlet Housing Authority? *

Yes

No

Have you or any other owners been convicted of a felony in the last 10 years? *

Yes

No

Have you received assistance from any of the following? (check all that apply) *

Alaska Small Business Development Center (AK SBDC)

Anchorage Community Land Trust (ACLT)

Alaska Women's Business Center

Alaska Veteran's Business Outreach Center

None of the above