Entrepreneur

Date of Birth (required)

First Name (required)

Last Name (required)

Street Address*

City Of Residence*

State*

Zip Code*

County*

Home Phone Number*

Cell Phone Number*

Work Phone Number*

Can you receive calls at work?*
YesNo

Email Address*

Class location will be the first floor conference room of the George Oaks Building at Hinds Community College, Vicksburg, MS.

Present employment status?*
Full Time (more than 35hrs/week)Part TimeFull Time Self EmployedPart Time Self EmployedSeasonal EmploymentUnemployed less than 6 monthsUnemployed more than 6 monthsUnemployed more than 2 years

What company?*

In what city is this company located?*

Have you ever operated a business?*
YesNo

Do you currently operate a business?*
YesNo

Business Name

Which of the following apply to you?* (Choose as many as you like)
Trying to decide if business ownership is right for more, or if my business idea is viable through the development of a plan.Need assistance and/or capital to stabilize my existing business.Need assistance and/or capital to expand my existing business.Other

If Other specify

The program cost is $85 which includes textbooks and materials. Please include all payment info below.

Credit Card Number (No dashes or Spaces)*

Name (As it appears on your card)*

Billing Zip Code*

Expiration Date*
01 - January02 - February03 - March04 - April05 - May06 - June07 - July08 - August09 - September10 - October11 - November12 - December
2019202020222023202420252026202720282029

Security Code *

I confirm that the payment information entered above is valid and agree to allow the Vicksburg-Warren Partnership to use the payment information to process a charge of $85 for this program.*