Resource Partner Intake Survey
This form can also be completed online at: https://www.surveymonkey.com/s/3SHPXGV
Please return completed form to Conaway Haskins by email at chaskins@vcen.org
Organization Name:
__________
Web site:
Contact Information
The person who will receive SourceLink Virginia referrals.
Name & Title:
Street Address:
City:
E-mail address:
State:
Tel # (
___
)
Zip Code:
Fax # (
)
Organization Director
Name, title, phone number & email address (if different from above)
_________________________________________________
_______________
Marketing Contact (if applicable) Name, title, phone number & email address
______________________________________________________
__________
Member Services Contact (if applicable) Name, title, phone number & email address
_______________________________________
_________________________
Name, title, phone & email of any others at your organization that want to receive SourceLink Virginia
newsletters and updates.
1
As a partner of SourceLink Virginia, your organization will have a listing on our Resource Navigator.
The Resource Navigator is our online tool that asks entrepreneurs a few questions about their
business needs and then provides the user with a list of organizations that can meet those needs.
The following information is needed to properly display your information in the Resource Navigator
and Resource Directory.
Logo (if available)
Email your logo to chaskins@vcen.org as a GIF or JPEG file (sized at 150x150 pixels max if possible)
Short statement about organization, which will appear in the Resource Directory 200
characters (about 30 words) MAX
________________________________________________________________________________
__________________________________________________________________
__________________________________
_________
___
Long description of organization, which will appear in the Resource Navigator
1,000 characters (about 150 words) MAX
___________________________________
_____________________________________
_____
________________________
___________________________
_____________________________________________
___________________
___________________________________________________
_____________
_________________________________________________________
_______
Do you have a newsletter? _________
Electronic or print? ________________
Please add SourceLink Virginia to your distribution list, chaskins@vcen.org
2
Resource Database Survey
Please answer the following questions as completely as possible. This will allow us to load the
Resource Navigator database with specific information about your organization so that we can refer
clients that match your services. You may check more than one response where choices are offered.
Demographics
Some service providers work with all types of entrepreneurs and business owners, others work only with
specific sub-groups. In each category below, please check the types of clients which you would like for us to
refer to you. If you do not limit your services to specific sub-groups, please mark all that apply.
Select every state of business that your organization serves:
__ Concept stage
__ Existing Business
__ Start-ups
__ Well Established (Revenues > $1 million)
Does your organization require that clients have a completed business plan?
__ Yes
__ No
Does your organization serve:
__ Only women
__ Only men
__ Both
If your organization targets a specific minority group or groups, please specify:
__ African American/Black __ American Indian/Alaskan Native
__ Asian
__ Caucasian/White
__ Hispanic
__ Native Hawaiian/Pacific Islander
__ Other ______________________________________________
Select every type of industry that your organization serves:
__ Agriculture & Forestry
__ Arts
__ Biosciences/Manufacturing
__ Construction
__ Education
__ Energy and Utilities
__ Finance and Insurance
__ Health and Child Care
__ High Tech
__ Hospitality
__ Information Technology
__ Management
__ Manufacturing
__ Mining
__ Nonprofit
__ Other Services
__ Personal Services
__ Professional Services
__ Real Estate
__ Restaurant
__ Retail
__ Tourism
__ Transportation/Warehousing
__ Wholesale
__ Wineries & Breweries
Do you provide services ONLY to clients who currently live in a specific city, county or state? If so, please list
_
_______________________________________________________
3
Please indicate the cities and counties that your organization serves:
Virginia (Statewide)
Accomack County
Albemarle County
Alexandria City
Alleghany County
Amelia County
Amherst County
Appomattox County
Arlington County
Augusta County
Bath County
Bedford County
Bland County
Botetourt County
Bristol City
Brunswick County
Buchanan County
Buckingham County
Buena Vista City
Campbell County
Caroline County
Carroll County
Charles City County
Charlotte County
Charlottesville City
Chesapeake City
Chesterfield County
Clarke County
Clifton Forge City
Colonial Heights City
Covington City
Craig County
Culpeper County
Cumberland County
Danville City
Dickenson County
Dinwiddie County
Emporia City
Essex County
Fairfax City
Fairfax County
Falls Church City
Fauquier County
Floyd County
Fluvanna County
Franklin City
Franklin County
Frederick County
Fredericksburg City
Galax City
Giles County
Gloucester County
Goochland County
Grayson County
Greene County
Greensville County
Halifax County
Hampton City
Hanover County
Harrisonburg City
Henrico County
Henry County
Highland County
Hopewell City
Isle of Wight County
James City County
King and Queen County
King George County
King William County
Lancaster County
Lee County
Lexington City
Loudoun County
Louisa County
Lunenburg County
Lynchburg City
Madison County
Manassas City
Manassas Park City
Martinsville City
Mathews County
Mecklenburg County
Middlesex County
Montgomery County
Nelson County
New Kent County
Newport News City
Norfolk City
Northampton County
Northumberland County
Norton City
Nottoway County
Orange County
Page County
Patrick County
Petersburg City
Pittsylvania County
Poquoson City
Portsmouth City
Powhatan County
Prince Edward County
Prince George County
Prince William County
Pulaski County
Radford City
Rappahannock County
Richmond City
Richmond County
Roanoke City
Roanoke County
Rockbridge County
Rockingham County
Russell County
Salem City
Scott County
Shenandoah County
Smyth County
Southampton County
Spotsylvania County
Stafford County
Staunton City
Suffolk City
Surry County
Sussex County
Tazewell County
Virginia Beach City
Warren County
Washington County
Waynesboro City
Westmoreland County
Williamsburg City
Winchester City
Wise County
Wythe County
York County
4
Services
This section will match prospective clients with the services you offer. Please use the list below and
highlight ONLY those services that you DIRECTLY PROVIDE, as opposed to services for which you
provide advice and/or would know where to refer the client.
Categories and Services List
Business Planning
Business Plan Consulting, Development and Review
Demographic/Census Data
Feasibility Studies
Forming a Business
Identification/Research of Foreign Markets
Market Plan Development
Market Research
Buying or Selling a Business
Buying or Selling a Franchise
Purchasing an Existing Business
Valuation
Economic and Site Development
Economic Forecast
Enterprise Zones
Environmental Compliance
Lease Review
Navigating Municipal Regulations
New Jobs Cash Incentive
Revitalization
Site Location Assistance
Tax Credits
Watershed Planning
Financial Resources and Assistance
Agriculture Loans/Tax Credits
Bookkeeping/Accounting Software Training
Budget, Financial Statement and Cash Flow Training
Credit Enhancement
Equity Providers
Financial Assistance for International Trade Shows
Insurance Requirements
Loan/Debt Providers
New Jobs Cash Incentive
Obtaining Debt Funding
Obtaining Equity Funding
Obtaining Government Funding
Real Estate Finance
Tax Credits
Technology Grants
Tourism Marketing Grants
Human Resources
Employee Development, Hiring and Policies
Retention
Workforce Incentives
Job Fair Recruitment
Recruitment Space
Finding Workers
New Jobs Cash Incentive
Import and Export Assistance
Financial Assistance for Exporting Activities
Identification/Research of Foreign Markets
Import/Export Certification and Licensing
Locating Foreign Distributors
Networking
Trade Education and Training
Internship Programs and Student Services
Internship Program
Student Marketing Projects
Student Research Projects
Youth Entrepreneurship Education
Legal Services
Contract Review
Environmental Compliance
Forming a Business
Lease Review
Patent Seminars
Patent, Trademark & Copyright Information
Libraries and Research Organizations
Business Research Resources
Demographic/Census Data
Land Record Research
Management Issues
Human Resources
Insurance Requirements
Leadership/Professional Development
Recruiting Assistance
Manufacturing, High Tech, Life Sciences Development
Commercialization
Hazardous Waste Generation Avoidance Training
High Tech Development
Industrial Technology Research
Life Sciences Development
Manufacturing Development
Pollution Prevention
Quality Improvement (Supply Chain, Six Sigma)
Technology Transfer
Wet Lab Incubator
Science/Bioscience Seminars
Health and Safety Training
Marketing/Sales
Advertising/Brochure Design
Competitive Analysis
Demographics/Census Data
E-Commerce/Internet Marketing
5
Feasibility Studies
Identification/Research of Foreign Markets
Market Plan Development and Training
Market Research
Student Marketing Projects
Website Development
Mentoring
Mentoring Programs
Mentoring Events
Networking Organizations
Agriculture Producer Groups
Demographically Based
Geographically Based
Home Based
Industry Specific
International Trade
Small Business/General
Nonprofit Development
Accounting
Board Development
Funds Development
Human Resources
Organizational Audits
Strategic Planning
Technical Services
Office, Incubator, Laboratory, Kitchen and Meeting Space
Artisan Center
Commercial Kitchen Facilities
Conference/Meeting and Event Space
Co-working Space
FabLab
Food Manufacturing Location Inspection
Incubator Space
Lease Review
Office Equipment and Furniture
Maker Space
Office Space
Recruitment Space
Retail Space
Site Location
Wet Lab Incubator
Operations and Logistics
Freight & Distribution
Hazardous Waste Generation Avoidance Training
Health and Safety Training
Locating Freight Forwarders/Custom Brokers
Pollution Prevention
Quality Improvement
Product Research and Development
Modelling and Simulation
Patent Information
Product Design & Development
Proof of Concept
Prototype Development
Testing and Validation
Public Policy and Government Relations
African American Business
Asian-American Business
Business Issues Related to a Specific City/County
Hispanic Business
Virginia Business Issues
Native American Business
Public Policy Related to Agriculture
Small Business Policy
Women’s Business Issues
Regulatory Compliance
Bonding
Codes
Environmental Compliance
Government Requirements
Insurance Requirements
International Regulatory Compliance
Patent Information
Registration, Licenses and Permits
Trademark & Copyright Information
Selling to the Government and Large Corporations
Bid Matching and Preparation
Government & Military Specifications
HUBZone Certification
Obtaining Corporate Contracts
Obtaining Government Contracts
Price History
Registration Assistance
Selling to Foreign Governments & Businesses
Subcontracting Opportunities
Women, Minority & Disadvantaged Business Certification
Starting a Business
Business Research Resources
Feasibility Studies
Forming a Business
Home-Based Business Training
Pre-Business Training
Registration, Licenses and Permits
Site Location
Startup Business Counseling
Startup Classes
Startup Funding
Farm Plans
Nutrient Management Plans
Pesticide Applicator Training
Soil Suitability Analysis
Tax Services
State and Federal Tax Training
State Tax Credit Information
Tax Credits
Tax Preparation Assistance
Tax Registration
Technical Assistance
Bookkeeping/Accounting Software Training
Commercialization
Industrial Technology Research
6
Pollution Prevention
Technology Transfer
Website Development
Training
Bookkeeping/Accounting Software Training
Budget, Cash Flow and Financial Statements Training
Business Management Training
Business Plan Training and Assistance
E-Commerce/Internet Marketing
Hazardous Waste Generation Avoidance Training
Health & Safety Training
Home-Based Business Training
Human Resources Training
International Trade Training
Marketing Plan Training
Pre-Business Training
Trade Education and Training
Startup Classes
Industry Specific Education and Training
Selling to the Government
Innovative Agriculture Training
General Business Training
Scrum and Agile Software Development
7