Register You’re about to start Fase1! Complete the form and you will be closer to the starting point. "* Required field" indicates required fields ¡Estás a punto de comenzar en Fase 1! Completa el formulario y estarás más cerca del punto de partida. Name* Required fieldFirst last name* Required fieldSecond last name* Required fieldEmail* Required field Phone* Required fieldDate of Birth* Required field MM slash DD slash YYYY Last four digits of your social security number* Required fieldAre you a resident of Puerto Rico?* Required field Yes No Were you a resident of Puerto Rico at the time of hurricanes Irma and Maria?* Required field Yes No If not, please explain:* Required fieldPhysical addressPhysical address - Line 1* Required fieldPhysical address - Line 2Physical address - City* Required fieldCityAdjuntasAguadaAguadillaAguas BuenasAibonitoAreciboArroyoAñascoBarcelonetaBarranquitasBayamónCabo RojoCaguasCamuyCanóvanasCarolinaCatañoCayeyCeibaCialesCidraCoamoComeríoCorozalCulebraDoradoFajardoFloridaGuayamaGuayanillaGuaynaboGuraboGuánicaHatilloHormiguerosHumacaoIsabelaJayuyaJuana DíazJuncosLajasLaresLas MaríasLas PiedrasLoizaLuquilloManatíMaricaoMaunaboMayagüezMocaMorovisNaguaboNaranjitoOrocovisPatillasPeñuelasPonceQuebradillasRincónRio GrandeSabana GrandeSalinasSan GermánSan JuanSan LorenzoSan SebastiánSanta IsabelToa AltaToa BajaTrujillo AltoUtuadoVega AltaVega BajaViequesVillalbaYabucoaYaucoPhysical address - State* Required fieldStatePuerto RicoPhysical address - Zip code* Required fieldMailing addressAddress - Check here if it's the same as the physical address Check here if it's the same as the physical address Mailing address - Line 1* Required fieldMailing address - Line 2Mailing address - City* Required fieldCityAdjuntasAguadaAguadillaAguas BuenasAibonitoAreciboArroyoAñascoBarcelonetaBarranquitasBayamónCabo RojoCaguasCamuyCanóvanasCarolinaCatañoCayeyCeibaCialesCidraCoamoComeríoCorozalCulebraDoradoFajardoFloridaGuayamaGuayanillaGuaynaboGuraboGuánicaHatilloHormiguerosHumacaoIsabelaJayuyaJuana DíazJuncosLajasLaresLas MaríasLas PiedrasLoizaLuquilloManatíMaricaoMaunaboMayagüezMocaMorovisNaguaboNaranjitoOrocovisPatillasPeñuelasPonceQuebradillasRincónRio GrandeSabana GrandeSalinasSan GermánSan JuanSan LorenzoSan SebastiánSanta IsabelToa AltaToa BajaTrujillo AltoUtuadoVega AltaVega BajaViequesVillalbaYabucoaYaucoMailing address -State* Required fieldStatePuerto RicoMailing address - Zip code* Required fieldEmployment Status* Required field Employed Not Employed Highest Level of Education* Required field Completed College Completed High School Some College Some High School Do you need assistance to develop your business idea?* Required field Yes No Do you want to develop a startup or small buisness and don’t know how?* Required field Yes No Are you interested in taking short courses and/or training to develop your business idea?* Required field Yes No Would you like to participate in an incubator program?* Required field Yes No Business InformationDo you have an established business?* Required field Yes No In development Business name* Required fieldBusiness EIN or Tax ID Number* Required fieldNumber of owners* Required field123456789Owner InformationComplete nameOwnership percentage Add RemoveNumber of employees (Do not include owners)* Required field0123456789101112131415Más de 15How many employees participate in Fase1?* Required field0123456789101112131415Más de 15Please provide name of employees participating in Fase1NamePhoneAddress Add RemoveReceived Financial AidHave you previously received any financial assistance for your business?* Required field Yes No List of financial assistance* Required field Small Business Administration (SBA) Federal Emergency Management Agency (FEMA) National Flood Insurance Program (NFIP) Private Insurance U.S. Department of Housing and Urban Development (HUD) Central Office For Recovery, Reconstruction, And Resiliency (COR3) Increased Cost of Compliance coverage (ICC) Nonprofit or Charitable Funding Community Development Block Grant Program - Coronavirus Response Grants (CDBG-CV) Business Interruption Grant (BIG) from the Puerto Rico Department of Economic Development and Commerce Economic Injury Disaster Loan (EIDL) from the Small Business Administration (SBA) Paycheck Protection Program (PPP) from the Small Business Administration (SBA) Private foundations Puerto Rican Central Government and Municipalities Other benefits or economic incentives Small Business Administration (SBA)Amount* Required fieldDate received* Required field MM slash DD slash YYYY Purpose of funding* Required fieldFederal Emergency Management Agency (FEMA)Amount* Required fieldDate received* Required field MM slash DD slash YYYY Purpose of funding* Required fieldNational Flood Insurance Program (NFIP)Amount* Required fieldDate received* Required field MM slash DD slash YYYY Purpose of funding* Required fieldPrivate InsuranceAmount* Required fieldDate received* Required field MM slash DD slash YYYY Purpose of funding* Required fieldU.S. Department of Housing and Urban Development (HUD)Amount* Required fieldDate received* Required field MM slash DD slash YYYY Purpose of funding* Required fieldCentral Office For Recovery, Reconstruction, And Resiliency (COR3)Amount* Required fieldDate received* Required field MM slash DD slash YYYY Purpose of funding* Required fieldIncreased Cost of Compliance coverage (ICC)Amount* Required fieldDate received* Required field MM slash DD slash YYYY Purpose of funding* Required fieldNonprofit or Charitable Funding (Red Cross, United Way, local church, etc.)Amount* Required fieldDate received* Required field MM slash DD slash YYYY Purpose of funding* Required fieldCommunity Development Block Grant Program - Coronavirus Response Grants (CDBG-CV)Amount* Required fieldDate received* Required field MM slash DD slash YYYY Purpose of funding* Required fieldBusiness Interruption Grant (BIG) from the Puerto Rico Department of Economic Development and Commerce (DDEC, for its Spanish acronym)Amount* Required fieldDate received* Required field MM slash DD slash YYYY Purpose of funding* Required fieldEconomic Injury Disaster Loan (EIDL) from the Small Business Administration (SBA)Amount* Required fieldDate received* Required field MM slash DD slash YYYY Purpose of funding* Required fieldPaycheck Protection Program (PPP) from the Small Business Administration (SBA)Amount* Required fieldDate received* Required field MM slash DD slash YYYY Purpose of funding* Required fieldPrivate foundationsAmount* Required fieldDate received* Required field MM slash DD slash YYYY Purpose of funding* Required fieldPuerto Rican Central Government and MunicipalitiesAmount* Required fieldDate received* Required field MM slash DD slash YYYY Purpose of funding* Required fieldOther benefits or economic incentivesAmount* Required fieldDate received* Required field MM slash DD slash YYYY Purpose of funding* Required fieldSBA LoansHave you applied for an SBA loan?* Required field Yes No Have you declined an SBA loan?* Required field Yes No What was the amount of the loan?* Required fieldWhy was the loan not accepted?* Required fieldFamily Income InformationIndicate your Head of Household Status selecting one of the following options.* Required field Single Head of Household - Female Single Head of Household -- Male Not a Single Head of Household Prefer not to answer Number of persons in your household* Required fieldSources of income* Required fieldTotal household income* Required fieldIndicate the annual family income * Select the box that represents the range of annual household income. Be sure to include all sources of income that apply: wages, earnings, welfare, child support, alimony, pensions, social security, child income, and/or any other income. The amount must be before any deductions for taxes, insurance, medical expenses, child support, etc.Select the appropriate range of combined annual income for all people in the household* Required fieldWhen selecting the number of people living in your household, look at the box below to select your income level. 1 2 3 4 5 6 7 8 More than 8 members in your household 1 - My annual Household income is: At or below $31,100 At or above $31,101 2 - My annual Household income is: At or below $35,550 At or above $35,551 3 - My annual Household income is: At or below $40,000 At or above $40,001 4 - My annual Household income is: At or below $44,400 At or above $44,401 5 - My annual Household income is: At or below $48,000 At or above $48,001 6 - My annual Household income is: At or below $51,550 At or above $51,551 7 - My annual Household income is: At or below $55,100 At or above $55,101 8 - My annual Household income is: At or below $58,650 At or above $58,651 **Note: Income information will not be used to determine eligibility for Fase1.Indicate your Race & Ethnicity selecting one of the options below* Required field American Indian/Alaskan Native Asian Black/African American Native Hawaiian/Other Pacific Islander White Indian/Alaskan Native & White Asian & White Black/African American & White Hispanic - American Indian/Alaskan Native Non-Hispanic - No Hispano/Latino Hispanic - Hispano/Latino Hispanic - Asian Non-Hispanic - No Hispano/Latino Hispanic - Hispano/Latino Hispanic - Black/African American Non-Hispanic - No Hispano/Latino Hispanic - Hispano/Latino Hispanic - Native Hawaiian/Other Pacific Islander Non-Hispanic - No Hispano/Latino Hispanic - Hispano/Latino Hispanic - White Non-Hispanic - No Hispano/Latino Hispanic - Hispano/Latino Hispanic - Indian/Alaskan Native & White Non-Hispanic - No Hispano/Latino Hispanic - Hispano/Latino Hispanic - Asian & White Non-Hispanic - No Hispano/Latino Hispanic - Hispano/Latino Hispanic - Black/African American & White Non-Hispanic - No Hispano/Latino Hispanic - Hispano/Latino Other Training ProgramsPlease indicate if you are currently enrolled or were enrolled in an equal or similar course (or courses) under any other CDBG-DR funded program* Required field Yes No Specify course or courses, program and dates.* Required fieldI/we certify that the information provided in this Workforce Training Intake Form is true and correct to the best of my knowledge. I/we acknowledge that false, misleading, or incomplete information constitutes just cause for denial of participation in the Community Development Block Grant – Disaster Recovery (CDBG-DR Program) Program. I further acknowledge that providing false, misleading or incomplete information may result in the restitution of funds incurred in any type of assistance provided to me under the Program. I/we agree to provide, upon request, documentation on all income sources to the Puerto Rico Department of Housing (PRDOH), the U.S. Department of Housing and Urban Development (HUD), and/or the Subrecipient. Warning: Any person who knowingly makes a false claim or statement to HUD may be subject to civil or criminal penalties under 18 U.S.C. § 287, 1001 and 31 U.S.C. § 3729.I understand that including my name in the box below is equivalent to accepting and signing this form.Name and both last names* Required fieldDate* Required field MM slash DD slash YYYY CAPTCHANameThis field is for validation purposes and should be left unchanged.
