All personal data will be kept confidential, and we will not share individual demographic data with any third party. National Disability Institute (NDI) collects data to help secure future funding to create programs that serve the community.
First Name - required*
Last Name - required*
Email Address - required*
State/Province - required* Select State/Province Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming Non US State or Territory
Organization
Job Title
Agency affiliation - required* Please select Entrepreneur / Small Business Owner Thinking of starting a business Entrepreneurial support organization Disability support organization CDFI/Bank/Credit Union State Vocational Rehabilitation Federal Government Other
Are you currently in business? - required* Please select Yes No, but I am thinking of starting a business No Prefer not to say
Annual Revenue - required* Please Select Pre-revenue $1 to $5,000 $5,001 to $25,000 25,001 to $100,000 $100,001 to $500,000 $500,001 to $1,000,000 $1,000,000 + Prefer not to say Not applicable
Industry - required* Please Select Agriculture, Forestry, Wildlife Business, Information Construction, Utilities Education Finance Government, Public Services Healthcare Health, Beauty, Fitness Hospitality, Food & Beverage Legal, Insurance Leisure: Gaming, Sports, Events Marketing, PR, Media Natural Resources, Environmental NGO, Nonprofit Personal Services: Home Goods, Services Real Estate Safety and Security Technology Travel, Transportation Other Prefer not to say Not applicable
Do you or someone in your household have a disability? required* Please select Yes, I have a disability Yes, someone in my household has a disability Yes, both I and someone in my household have disabilities No, neither I nor anyone in my household has a disability Prefer not to answer
ASL Interpretation and captioning will be provided for all sessions. If you would like to request an accommodation to participate in this convening, please specify in the space below.
Race / Ethnicity - required* Please select all that apply: Gender Identity - required* Please select Female Male Transgender Nonbinary / gender non-conforming Other Prefer not to say
L-G-B-T-Q-I-A+ - required* Please select L-G-B-T-Q-I-A+ Not L-G-B-T-Q-I-A+ Other Prefer not to say
Military Service - required* Please select Yes No Prefer not to say
I would like to subscribe to the small business mailing list. - required* Please select Yes No Already subscribed
