<p> 294 WASHINGTON STREET, SUITE 443 BOSTON, MASSACHUSETTS 02108 TEL (617) 482-1145 FAX (617) 482-4392 [email protected] www.lawyers com.org </p><p>Economic Justice Project General Intake Form</p><p>Personal Information</p><p>Name: ______</p><p>Home Address: ______</p><p>City: ______State: ______Zip: ______</p><p>Phone: ______Email: ______</p><p>Sex: Female Male Other </p><p>Race/Ethnicity: </p><p>African American European American/Caucasian </p><p>Latina/Latino/Hispanic</p><p>Native American Pacific Islander Asian </p><p>Caribbean American Middle Eastern Indian</p><p>Is English your first language? Yes No (Please specify first language) ______</p><p>Are you currently a U.S. Citizen? Yes No</p><p>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</p><p>If yes (please describe): ______</p><p>1</p><p>Business Information</p><p>Name of your new or existing business: ______</p><p>Briefly describe your business or business idea? (e.g., the type of services and products your business offers) </p><p>Business Email Address: ______</p><p>Mailing Address: ______</p><p>City: ______State: ______Zip: ______</p><p>Business Phone Number: ______</p><p>Do you have any entrepreneurial training or experience? Yes No </p><p>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?)</p><p>Are you currently conducting business? Yes No </p><p>If yes, when did you begin? ______</p><p>How many people work for your business? Full time Part-time Contractors</p><p>How many people do you anticipate hiring over the next 3 years? </p><p>How did you hear about the Lawyers’ Committee:</p><p>Financial Information * Please include a copy of your most recent yearly tax return </p><p>How many people are in your household? </p><p>How many are dependents? </p><p>What is the total annual gross income from all members of your household? </p><p>2</p><p>What is your gross annual income? </p><p>What is the source of your income? </p><p>Is your business being financed in part or in full by a source other than yourself? Yes No </p><p>Have you applied for any loans to finance your business? Yes No </p><p>Do you have any partners in your business? Yes No </p><p>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 </p><p>If yes, please specify: </p><p>Legal Business Assistance</p><p>What legal services do you think you need?</p><p>Entity Formation (For example, forming a corp. or LLC) Purchase of Commercial </p><p>Property</p><p>Intellectual Property (Trademark, copyright, patent) Employment Law Concerns</p><p>Contract Drafting/Review Franchising</p><p>Lease Review Zoning Compliance</p><p>Business Acquisition Other (please describe below)</p><p>Has an attorney helped you with your business at any time? Yes No </p><p>If yes, for what matter(s)? ______</p><p>Have you received assistance from an organization on starting your own business) e.g., business plan, marketing, financial management)? Yes No </p><p>If yes, please provide the name of the organization and contact person: ______</p><p>Have you ever applied to the Lawyers’ Committee before? Yes No </p><p>3</p><p>If yes, please specify when: ______</p><p>Please include a brief description of your legal needs below:</p><p>4</p>