Entrepreneur Intake Form
Personal Information
In order to assist you in developing your project, it is important for us to thoroughly understand your business project and its components. A Business Advisor will gladly help you in the process.
First Name
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Last Name
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Street Address
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Address Line 2
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City
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Country
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Select Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua & Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahama
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Iislands
Costa Rica
Côte d’Ivoire (Ivory Coast)
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard & McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iraq
Ireland
Islamic Republic of Iran
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova, Republic of
Monaco
Mongolia
Monserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russian Federation
Rwanda
Saint Lucia
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
St. Helena
St. Kitts and Nevis
St. Pierre & Miquelon
St. Vincent & the Grenadines
Sudan
Suriname
Svalbard & Jan Mayen Islands
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania, United Republic of
Thailand
Togo
Tokelau
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom (Great Britain)
United States Minor Outlying Islands
United States of America (USA)
United States Virgin Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City State (Holy See)
Venezuela
Viet Nam
Wallis & Futuna Islands
Western Sahara
Yemen
Yugoslavia
Zaire
Zambia
Zimbabwe
Province
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Postal Code
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Telephone
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Email
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Business Name
Please indicate which of the following apply to you (check off all that apply):
*
Youth (between 18 and 39)
Currently receiving Employment Insurance
Employed
Unemployed
Received Employment Insurance Benefits in the last 36 months
N/A
In which municipality will you operate your business?
Dieppe
Moncton
Riverview
Other
Has your business been operating for more than one year?
Yes
No
Are you looking for Financing?
Yes
No
Are you looking for Training?
Yes
No
How did you hear about the Southeast Regional Service Commission?
*
The Southeast Regional Service Commission provides business counseling and other services to entrepreneurs and business owners free of charge. Our business counselors can help you with many facets of your Startup or Small Business. Confidentiality is guaranteed and information is only shared with partners with your consent.
The information presented by the Southeast Regional Service Commission is not intended to be all-inclusive and does not constitute legal, tax, or accounting advice, but is designated to provide general information in relation to your Business Startup. It is the sole responsibility of business owners and entrepreneurs to fully understand all legal, tax, insurance, and any other requirements for your individual business. It is highly recommended that business owners consult with a lawyer of their choosing to help them understand legal issues pertaining to their business.
I accept that the Southeast Regional Service Commission and its representatives share the information contained in my Preliminary Business Outline, and any other related information with other appropriate economic development agencies and organizations, for the sole purpose of identifying all the resources available for my business project. Your consent will be sought before forwarding any information to partners.
I Accept
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Date
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