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Registration Form
Disability Owned Virtual Convening, October 31 - November 2, 2023: 12.30 PM to 5 PM ET
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
I consider myself to be (Please select all that apply) - required*
Entrepreneur or thinking of starting a business
Entrepreneurial support organization staff
Disability support organization staff
CDFI/Bank/Credit Union staff
State Vocational Rehabilitation staff
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 consider yourself a person with a disability? - required*
Please select
Yes
No
Prefer not to say
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 (Please select all that apply) - required*
American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian or Pacific Islander
White
Other
Prefer not to say
Ethnicity - required*
Please select
Hispanic or Latino
Not Hispanic or Latino
Prefer not to say
Other
Gender Identity - required*
Please select
Female
Male
Nonbinary
Prefer not to say
Other
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+
Prefer not to say
Other
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
By participating in this Convening hosted by NDI, you automatically agree to authorize recording of audio and visual content presented during the live event and consent to subsequent use of the recording in the public domain by NDI. The audio and visual recording of the live webinar includes documents and materials exchanged or viewed during the live event; questions asked, and poll answers provided by you during the live event; the closed captioning transcript; and the chat box transcript. - required*
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