Request For Services

Thank you for taking the time to fill out the information below. MCE values and protects your privacy. Information you provide is collected for statistical purposes and is for internal use only. Personal information will not be shared or given to any third party.

First Name: *

Last Name: *

MI:

Mailing Address: *

City: *

State: *

Zip Code: *

Residence Address: *

City: *

State: *

Zip Code: *

Best Phone Number: *

Fax Number:

E-Mail: *

Web Address:

Business Name: *

Business Phone Number: *

Business Fax Number:

Business Address: *

City: *

State: *

Zip Code: *

Ethnicity: *

Gender: *

Male

Female

Do you have a disability?: *

Yes

Your age group: *

Are you currently receiving TANF?: *

Yes

TANF - Temporary Assistance for Needy Families

How many people are in your household?: *

Currernt annual household income: *

Household income includes all working members (full-time or part-time)in the household regardless of their membership to you

Employment status: *

Full Time if working over 35 hours per week

Annual wage at job: *

If unemployed, please select $0.

Do you currently own a business?: *

Yes

Please describe your business: *

For existing businesses type here what kind of business it is or your business idea for the start-up

Date business started:

Is this business full time or part time?:

Full time if business is operating over 35 hours per week

Do you have paid employees?: *

Yes

If yes, total number of paid employees in last 12 Months:

How many of them are full time? :

35 hrs/week

How many of them are part time?:

<35 hrs/week

How many of them are seasonal or temporary?:

Your business last years gross sales: *

Did you take any money out of business for personal expenses last year?: *

Would you like to be added to MCE's email list to be notified of upcoming training seminars and workshops?: *

What services are you looking for? : *

If interested in a business loan, what is the amount needed?: * $

How did you hear about us?: *

Client Acknowledgement:

Print your name : *

Date: *

Office Location:

144 East Main Street
Salisbury, MD

1800 N Charles St, Ste 808
Baltimore, MD

Mailing Address:

P.O. Box 213
Salisbury, MD 21803

Phone: 410NoSkype-546-1900
Fax: 410-546-9718
Email:info@marylandcapital.org

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