SBEP Application Form
Thank you for your interest in the Small Business Executive Program (SBEP). Applications must be completed in full to be considered for the program. Selected participants must attend ALL sessions to qualify for a certificate after the program is completed.
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General Information
Class *
Jacksonville SBEP Class XIV Fall 2023
First Name *
Middle Name
Last Name *
Title or Position *
Highest Education Level *
Some High School High School Diploma or Equivalent Some College Technical Degree AA or 2-year Degree BA or BS Masters Level Degree JD/MD Degree Doctorate/PhD
Birth Date
Race/Ethnicity
American Indian / Alaska Native Asian Black / African American Hispanic / Latino Native Hawaiian / Pacific Islander White / Caucasian
Gender
Female
Male
Personal Contact Information
Email Address *
Phone *
Phone Type *
Home
Mobile
Other
Work
Home Address 1 *
Home Address 2
Home City *
Home State *
Home Zip Code *
Business Information
Business Name *
Company Name (if different than DBA)
Phone2 *
Phone Type 2 *
Home
Mobile
Other
Work
Address 1 *
Address 2
City *
State *
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
American Samoa
Federated States of Micronesia
Guam
Marshall Islands
Northern Mariana Islands
Palau
Puerto Rico
U.S. Minor Outlying Islands
Virgin Islands
Armed Forces Americas
Armed Forces Europe, the Middle East, an
Armed Forces Pacific
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut Territory
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon Territory
Zip Code *
Address Type
Home
Work
School
Other
Website
Type of Business *
Accommodation & Food Services Administrative & Support Services Agriculture, Forestry, Fishing & Hunting Arts, Entertainment & Recreation Construction Educational Services Finance & Insurance Health Care & Social Assistance Information Management of Companies & Enterprises Manufacturing Other Services (except Public Administration) Professional, Scientific & Technical Services Public Administration Real Estate Rental & Leasing Retail Trade Transportation & Warehousing Utilities Waste Management & Remediation Services Wholesale Trade
Describe your Business *
Year Business was Founded (yyyy) *
Your Percent Ownership *
Legal Entity of Business *
Corporation LLC Nonprofit Partnership S-Corporation Sole Proprietorship Not Yet Established Other
If "Other", please specify
Are you the Business Founder? *
Yes No
Is this a Family Business? *
Yes No
Do you Conduct Business Online? *
Yes No
Is this a Home-based Business? *
Yes No
Does your Business Export? *
Yes No
2023 Full-time Employees (#) *
2023 Part-time Employees (#) *
2023 Contract Employees (#) *
2022 Gross Revenue *
2022 Profit/Loss *
Annual Personal Compensation *
<$50,000 $51,000-$100,000 $101,000-$150,000 $151,000-$200,000 $201,000-$250,000 >$250,000
Work Experience
Please list your past positions in reverse chronological order, starting with your most recent positions.
Name of Company *
Title or Position *
From-to (Year) *
_
Name of Company
Title or Position
From-to (Year)
Social Media
Please provide links to your personal social media pages.
www.facebook.com/
www.instagram.com/
www.linkedin.com/in/
www.twitter.com/
Narrative
Please describe your role and the critical decisions in which you are involved.
Role and Decisions *
What are your most important business goals for the next five years?
Business Goals *
Please describe the personal objectives you hope to achieve through participation in the SBEP and how they relate to the needs of your business.
Personal Objectives *
Do you have any concerns about participation in the Small Business Executive Program?
Concerns *
How did you hear about the program? *
Separate from this program, the Jim Moran Institute offers exclusive programs for FSU alumni and for military veterans. For informational purposes only:
Have you attended Florida State University?
Yes No
Are you a Veteran?
Yes No
Are you an immediate family member of a Veteran?
Yes No
By submitting this application, I acknowledge that attendance and participation in all sessions is mandatory. In addition, I consent to allow the Jim Moran Institute to use all photographs and videos taken at this event in future marketing efforts.
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