NCDE Application A A A www.viscardicenter.org > NCDE Application Share on Facebook Click to share on Twitter Click to share on Google+ Click to share on LinkedIN CONTACT DETAILSName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you use a different Mailing Address?*YesNoIf yes, please provide your Mailing Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Preferred Phone #1:*Preferred Phone #2:*Preferred Email Address:* Business Website: LinkedIn: Twitter: Snapchat: Instagram: Facebook: TikTok: Please disclose your disability:*How did you learn about the National Center for Disability Entrepreneurship at The Viscardi Center? Please check all that apply.* Disability Service Provider/Program Disability Scoop Online Search Media Article Digital Ad Social Media Flyer Friends or Family Email or E-News Previous NCDE program participant Through The Viscardi Center If you selected, "Through The Viscardi Center" in the previous question, please tell us how you heard about the program. E-Blast Social Media Signage Viscardi Alumni Group Word-of-Mouth Other (please note below) If other, please describe: PERSONAL INFORMATIONGender*MaleFemaleOtherDate of Birth* MM slash DD slash YYYY Marital Status*Single, Never MarriedMarriedDivorcedWidowedSeparatedLife PartnerWhat is your race/ethnicity? (Check all that apply)* American Indian/Native American Asian Black or African American Hispanic or Latino Native Hawaiian or Pacific Islander White/Caucasian Other, Specify Below If other, please specify: EDUCATIONHighest Level of Education*Elementary/Junior High SchoolHigh SchoolVocational SchoolCollege/UniversityGraduate SchoolName of School* Location of School (City, State)* Start Date* MM slash DD slash YYYY End Date* MM slash DD slash YYYY Name of School Location of School City, State) Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Name of School Location of School City, State) Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Diplomas, Degrees, Certificates, Dates Received*NCDE PROGRAMIn 500 words or less, please describe why you want to participate in the NCDE program.*Have you already started a business (i.e. you have customers who have used the product/service)?*YesNoIf yes, in 500 words or less, please describe the business product/service, if you have employees (how many), what is the approximate annual revenue and if you have it, your business website.If no, in 500 words or less, please describe your business idea. (Include the steps you have taken to research the industry and potential customers/target audience.)In 500 words or less, please describe what challenges have you faced in starting your business, or in your research to start it. What support and resources would meet your immediate needs to start or grow your business?*In 500 words or less, please describe what factors in your background (education, work, life experiences, support network, family, and friends) prepare you to be an entrepreneur.*Please indicate if there are any specific time periods during the year that you would be unavailable to participate in the NCDE program, if selected to participate.*CURRENT SUPPORT SYSTEMPlease tell us, in 500 words or less, about any family, friends, current, or former co-workers, teachers, or care team members you feel are/would be most supportive of your decision to pursue self-employment and why.*PROGRAM EXPECTATIONS/OUTCOMESPlease tell us, in 500 words or less, what expectations you may have about the NCDE program, or outcomes you may anticipate from participating in it.*TELL US MORE ABOUT YOURSELFWe welcome any additional information about you that you feel will be helpful to better understand your goals for self-employment.