Empowering innovative self-starters to self-employment success The National Center for Disability Entrepreneurship is a competitive and sought-after program. It provides an intense skill building curriculum as well as tremendous resources. Therefore, the selection process is rigorous. Further, you must: be 18 years of age or older have an 8th grade reading level live in the United States Our committee assesses your "whole person" potential to excel both in the program and post- program. It is in your best interest to provide complete and thorough responses. Please find the application below. Once complete, please email it to: [email protected] THE APPLICATION DEADLINE FOR THE 2021 NCDE PROGRAM IS: MONDAY, MARCH 22, 2021. *Indicates mandatory field *CONTACT DETAILS *First Name: *Last Name: *Street Address: *State: *Zipcode: *Do You Use a Different Mailing Address? Y ___ N *If Yes, please provide your Mailing Address in the United States: Street Address State Country Zipcode Preferred Phone #1 Preferred Phone #2 Preferred Email If you have one, please provide the URLs/Handles to your: Business Website LinkedIn Twitter Snapchat Instagram Facebook TikTok *Please disclose your disability: *How did you learn about the National Center for Disability Entrepreneurship at The Viscardi Center? Please check all that apply. ☐ Disability Service Provider/Program ☐ Disability Scoop ☐ Online Search ☐ Media Article ☐ Digital Ad ☐ Social Media ☐ Flyer ☐ Friends or Family ☐ Email or E-News ☐ Previous NCDE Program Participant Through The Viscardi Center [TVC], please check all that apply: ☐ E-Blast ☐ Social Media ☐ Signage ☐ TVC Almuni Group ☐ Word of Mouth ☐ Other, please specify: *PERSONAL INFORMATION *Gender: Male ☐ Female ☐ Other ☐ *Date of Birth: Month Day Year *Marital Status: ☐Single, Never Married ☐ Married ☐ Divorced ☐ Widowed ☐ Separated ☐ Life Partner *What is your race/ethnicity? (please check all that apply) ☐ American Indian/Alaskan Native ☐ Asian ☐ Black or African American ☐ Hispanic or Latino ☐ Native Hawaiian or Pacific Islander ☐ White/Caucasian ☐ Other, please specify: *EDUCATION *Highest Level of Education: ☐ Elementary/Junior High School ☐ High School ☐ Vocational School ☐ College/University ☐ Graduate School *Educational Institutions: Name of School *Location of School: City State Zipcode *Start Date Month Year *End Date Month Year Name of School Location of School: City State Zipcode Start Date Month Year End Date Month Year Name of School Location of School: City State Zipcode Start Date Month Year End Date Month Year *Diplomas, Degrees, Certificates, Dates Received: *NCDE PROGRAM *In 500 words or less, please describe why you want to participate in the NCDE program. *Have you already started a business (i.e. you have customers who have used the product/service)? ☐ Yes ☐ No If “Yes” In 500 words or less, please describe the business product/service, if you have employees (how many), what is the approximate annual revenue and if you have it, your business website. If “No” In 500 words or less, please describe your business idea. (Include steps you have taken to research the industry and potential customers/target audience.) *In 500 words or less, please describe what challenges have you faced in starting your business, or in your research to start it? What support and resources would meet your immediate needs to start or grow your business? *In 500 words or less, please describe what factors in your background (education, work, life experiences, support network, family, and friends) prepare you to be an entrepreneur? *Please indicate if there are any specific time periods during the year that you would be unavailable to participate in the NCDE program, if selected to participate. *CURRENT SUPPORT SYSTEM *Please tell us in 500 words or less, about any family, friends, current or former co- workers, teachers, or care team members you feel are/would be most supportive of your decision to pursue self-employment and why. *PROGRAM EXPECTATIONS/OUTCOMES *Please tell us in 500 words or less, what expectations you may have about the NCDE program, or outcomes you may anticipate from participating in it. TELL US MORE ABOUT YOURSELF We welcome any additional information about you that you feel will be helpful to better understand your goals for self-employment. [500 words or less] .