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NCDE Application

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CONTACT DETAILS
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Do you use a different Mailing Address?*
If yes, please provide your Mailing Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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 INFORMATION
Gender*
Date of Birth*
Date Format: MM slash DD slash YYYY
Marital Status*
What 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:
EDUCATION
Highest Level of Education*
Name of School*
Location of School (City, State)*
Start Date*
Date Format: MM slash DD slash YYYY
End Date*
Date Format: MM slash DD slash YYYY
Name of School
Location of School City, State)
Start Date
Date Format: MM slash DD slash YYYY
End Date
Date Format: MM slash DD slash YYYY
Name of School
Location of School City, State)
Start Date
Date Format: MM slash DD slash YYYY
End Date
Date Format: MM slash DD slash YYYY
Diplomas, Degrees, Certificates, Dates Received*
NCDE PROGRAM
In 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)?*
If 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 SYSTEM
Please 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/OUTCOMES
Please 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 YOURSELF
We welcome any additional information about you that you feel will be helpful to better understand your goals for self-employment.