Economic Justice Project General Intake Form

294 WASHINGTON STREET, SUITE 443 BOSTON, MASSACHUSETTS 02108 TEL (617) 482-1145 FAX (617) 482-4392 [email protected] www.lawyers com.org

Personal Information

Name: ______

Home Address: ______

City: ______State: ______Zip: ______

Phone: ______Email: ______

Sex: Female Male Other

Race/Ethnicity:

African American European American/Caucasian

Latina/Latino/Hispanic

Native American Pacific Islander Asian

Caribbean American Middle Eastern Indian

Is English your first language? Yes No (Please specify first language) ______

Are you currently a U.S. Citizen? Yes No

Do you have a disability or chronic health condition that significantly limits any of your daily activities or the kind or amount of work you can do? Yes No

If yes (please describe): ______

Business Information

Name of your new or existing business: ______

Briefly describe your business or business idea? (e.g., the type of services and products your business offers)

Business Email Address: ______

Mailing Address: ______

City: ______State: ______Zip: ______

Business Phone Number: ______

Do you have any entrepreneurial training or experience? Yes No

What community will you, or do you presently, serve with your business and what benefits will the community receive, if any? (For example, will your business hire employees from the community?)

Are you currently conducting business? Yes No

If yes, when did you begin? ______

How many people work for your business? Full time Part-time Contractors

How many people do you anticipate hiring over the next 3 years?

How did you hear about the Lawyers’ Committee:

Financial Information * Please include a copy of your most recent yearly tax return

How many people are in your household?

How many are dependents?

What is the total annual gross income from all members of your household?

What is your gross annual income?

What is the source of your income?

Is your business being financed in part or in full by a source other than yourself? Yes No

Have you applied for any loans to finance your business? Yes No

Do you have any partners in your business? Yes No

Do you have other significant financial obligations (such as child care, educational expenses, child support or alimony that would assist us in evaluating your application)? Yes No

If yes, please specify:

Legal Business Assistance

What legal services do you think you need?

Entity Formation (For example, forming a corp. or LLC) Purchase of Commercial

Property

Intellectual Property (Trademark, copyright, patent) Employment Law Concerns

Contract Drafting/Review Franchising

Lease Review Zoning Compliance

Business Acquisition Other (please describe below)

Has an attorney helped you with your business at any time? Yes No

If yes, for what matter(s)? ______

Have you received assistance from an organization on starting your own business) e.g., business plan, marketing, financial management)? Yes No

If yes, please provide the name of the organization and contact person: ______

Have you ever applied to the Lawyers’ Committee before? Yes No

If yes, please specify when: ______

Please include a brief description of your legal needs below: