Valley Community Development Small Business Intake Form

Disclosures: Valley Community Development will follow strict rules to protect your confidentiality.  The personal data collected below including name, street address, email address and any other personally identifiable information is protected by the Data Privacy Act. You will never be named in any reports.  Your responses may be looked at individually by the funding source, or contractors hired by the funding source to collect and analyze data, your name or street address will not be reported.  Income, city, state, zip code, family size, and other demographic data will be reported.  Contractors of HUD/DHCD or any City/State agency are covered by the same Data Privacy Act requirements to protect your privacy and staff must demonstrate that they have systems in place to protect against data disclosure.

Contact Information






Please include apartment or suite number if applicable.






Business Information
(If you do not have official business information, enter your personal information.)

If you do not have a business name, please leave this field blank.

Please include apartment or suite number if applicable.










For example: restaurant, pet groomer, acupuncture


If you are paying yourself, please count yourself as an employee.






Demographic Information

Your gross annual income is required data needed to fund our Valley Community Development Small Business Program. Your data is only shared for reporting purposes and we prioritize our clients' confidentiality. Please enter a number only, with no characters.





Valley asks the following two questions as a requirement from several funding sources that help make our programs free to the community.



Racial categories defined by OMB & US Census.












Contact Information