Entrepreneurship as a Second Chance Program Application

Contact Information

First Name

Middle Name

Last Name

Mobile Phone

Home Phone

Address

City

State

Postal Code

New Jersey County

County

How did you hear about us?

Referred by

Please specify the organization that referred you

Demographic Information

Birthdate

Other Race

Ethnicity

Gender

Other Gender

Veteran Status

Are you a US Citizen?

Are you a Green Card Holder?

Are you on a Work Visa?

Court Information

Reason for incarceration

Length of incarceration (months)

Number of times incarcerated or serving court-ordered community service?

Most recent release date

Where were you incarcerated through?

Please specify what facility you were in

Do you have any mentors, advisors, or belong to any support groups? Please list them.

Education

Highest grade of school completed

List of skills, certifications, or licenses

Work History

Name of most recent employer

Start Date

End Date (if not current)

Job Description

Full time (over 20 hours per week) or part time?

Specify any other work experience relevant to your business idea

Business Idea/Experience

Do you have experience owning your own business?

Please explain

Do you have an idea for a business?

Please describe the product/service/business in 2 sentences.

Do you have any legal restrictions on the type of work you can do?

Please explain

Reference and Additional Information

Please provide any work-related references

	Name	Phone Number
Reference 1
Reference 2
Reference 3

Could you commit to full participation in this program, which includes class meetings from 10:30 AM to 12:30 PM for 7 consecutive Wednesdays, as well as 2–4 hours for assignments and/or counseling time?

Please explain

Do you have any current physical or mental health issues that would impact your ability to operate your business?

Please explain

Please specify other debt type

Describe your current living situation

Are you under any legal driving restriction?

Please specify your legal driving restriction

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