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204.141.32.97
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Submitted URL: https://www.sbir.contact/
Effective URL: https://forms.zohopublic.com/stoenmollman/form/641Form/formperma/JiAjo3ZAZFUp6zJRq9hPYQpus5PnM8786-WvUw-5vH0
Submission: On December 11 via api from US — Scanned from DE
Effective URL: https://forms.zohopublic.com/stoenmollman/form/641Form/formperma/JiAjo3ZAZFUp6zJRq9hPYQpus5PnM8786-WvUw-5vH0
Submission: On December 11 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
<form id="test"><input type="hidden" name="formName" value="641Form" id="formName"><!-- Form Perma will be sent only for PermaUrls -->
<input type="hidden" name="formPerma" value="JiAjo3ZAZFUp6zJRq9hPYQpus5PnM8786-WvUw-5vH0" id="formPerma"><input type="hidden" name="referrerName" id="referrerName" value="null"><input type="hidden" name="isPaymentForm" value="false"
id="isPaymentForm"><input type="hidden" name="formType" value="0" id="formType">
<input type="hidden" id="zf_date_format" datelocale="en-GB" name="date_format" value="dd-MMM-yyyy"><input type="hidden" name="isDocsPublicForm" value="false" id="isDocsPublicForm">
<input type="hidden" name="formrid" value="" id="formrid">
<input type="hidden" name="resizeform" value="0" id="resizeform">
<div id="zf_utmTrack" style="display: none;"></div>
<div class="templateWrapper" id="formRedirectURL" style="min-height:1070px;">
<ul class="tempHeadBdr formRelative">
<li class="tempHeadContBdr"><span id="logo-formheader" class="formLogo" style="display: none"><img aria-hidden="true" id="logo-formheader-img" src=""></span>
<h2 class="frmTitle" role="heading" aria-level="1"><em>SD SBDC Request for Counseling Form</em></h2>
<p class="frmDesc">SBA Form 641 equivalent</p>
<div class="clearBoth"></div>
</li>
</ul>
<!-- 'FieldElement' class is imported in order to get the key for display name of the component of 'Address' field.
'FormField' class is used to get field type of Zoho CRM field.-->
<div id="formBodyDiv" class="formRelative subContWrap rightAlign"><!-- <button elname="openPopUpSubForm" onclick="openPopUp();event.preventDefault()"> Open subform pop up </button> -->
<!-- formFieldWrapper class is used to differantiate form fields and subform fields in themes. Direct children (li) are considered as form fields. Dont change the order of class used. -->
<ul elname="formBodyULName" class="ulNoStyle formFieldWrapper" page_no="1" needpagedata="true">
<!-- i) Private form, ii) Perma, iii) Shared form, iv) Theme preview, v) Current Theme -->
<!-- "isVisible"="false": This 'Admin Only' field must not be shown to user. -->
<!-- "isVisible"="true": Case 1: This is not an 'Admin Only' field. Case 2: This 'Admin Only' field must be shown to user. -->
<!-- Theme Preview, Current Theme - Admin Only fields will be shown. Formula won't be calculated. Field Rules won't be executed. -->
<!-- formMetaData.key=Field link name -->
<!-- Zoho CRM field : "FIELD_LIST" key won't be present. -->
<li class="tempFrmWrapper name namemedium zfSelect2CustomCont" elname="livefield-elem" comptype="7" needdata="true" id="Name-li" compname="Name" linkname="Name" isvisible="true" mandatory="true" page_no="1" page_link_name="Page"
regex_type="0" showlabel="true" counteruid="">
<label class="labelName" id="Name-arialabel">
<span>Name</span>
<em class="important" aria-hidden="true">*</em>
</label>
<div class="subFrmFieldsHidden subFrmFieldsHiddenCont" style="display:none" elemname="fieldHiddenDiv"><em><svg class="icon icon-Denied-1-01">
<use xlink:href="#icon-rules-denied-01"></use>
</svg></em>
<span>N/A</span>
</div>
<div class="tempContDiv twoType" elemname="fieldContentDiv">
<div class="nameWrapper">
<span elname="compEachElem">
<span class="sr-only" elname="ariaReqSpan" id="ariarequired-Name0">Required</span>
<input aria-labelledby="Name-arialabel aria-showelemslabel-Name0 ariarequired-Name0" aria-describedby="hint-Name" onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="given-name" type="text" maxlength="255" elname="First"
name="Name" complink="Name_First" value="" mandatory="true" placeholder="">
<label id="aria-showelemslabel-Name0" elname="formSubInfoText" class="formSubInfoText">First Name</label>
</span>
<span elname="compEachElem">
<span class="sr-only" elname="ariaReqSpan" id="ariarequired-Name1">Required</span>
<input aria-labelledby="Name-arialabel aria-showelemslabel-Name1 ariarequired-Name1" aria-describedby="hint-Name" onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="family-name" type="text" maxlength="255" elname="Last"
name="Name" complink="Name_Last" value="" mandatory="true" placeholder="">
<label id="aria-showelemslabel-Name1" elname="formSubInfoText" class="formSubInfoText">Last Name</label>
</span>
<div class="clearBoth"></div>
</div>
<p class="errorMessage" elname="error" id="error-Name"></p>
</div>
<div class="clearBoth"></div>
</li>
<li isunique="false" class="tempFrmWrapper phone small" elname="livefield-elem" comptype="11" id="PhoneNumber-li" needdata="true" compname="PhoneNumber" linkname="PhoneNumber" isvisible="true" mandatory="true" page_no="1"
page_link_name="Page" showlabel="true" counteruid="" need_reconf="false">
<label id="PhoneNumber-arialabel" class="labelName">
<span>Phone</span>
<em class="important" aria-label="Required">*</em>
</label>
<div class="subFrmFieldsHidden subFrmFieldsHiddenCont" style="display:none" elemname="fieldHiddenDiv"><em><svg class="icon icon-Denied-1-01">
<use xlink:href="#icon-rules-denied-01"></use>
</svg></em>
<span>N/A</span>
</div>
<div class="tempContDiv" elname="phoneFormatElem" phoneformat="INTERNATIONAL" elemname="fieldContentDiv" incwebhk_name="fieldContentDiv">
<div elname="phoneFld" name="phone-elements">
<b class="inptCont">
<input name="PhoneNumber" aria-describedby="hint-PhoneNumber" aria-labelledby="PhoneNumber-arialabel" onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="tel" id="PhoneNumber" type="text" elname="countrycode" maxlength="20" value="" initalvalue="" iscodeenabled="false" phoneformattype="1" placeholder="">
</b>
</div>
<p class="errorMessage" elname="error" id="error-PhoneNumber"></p>
<script type="module">
if (false == true && (true)) {
var allowedCountryList = [];
var ipBasedCurrentCountry = null;
var defaultCountry = ""; // No I18N
var keyId = $("#PhoneNumber");
var keyIdConf = ("#" + "PhoneNumber" + "-reconf"); // No I18N
var listofcountries = [],
hasCode = false;
var initialCountry = "auto"; // No I18N
var countryCodeProps = jQuery.extend(true, {}, ZFPhone.countryCodeProps);
var isRtlEnabled = false;
var txtDir = "1"; // No I18N
if (txtDir != null && txtDir != undefined) {
if (txtDir == 2) {
isRtlEnabled = true;
}
}
countryCodeProps.isRtl = isRtlEnabled;
if (defaultCountry != "") {
defaultCountry = countryUniqueCode[""]; // No I18N
}
if (allowedCountryList.length > 0) {
var phoneVal = ""; // No I18N
var codeVal = ""; // No I18N
for (var itr = 0; itr < allowedCountryList.length; itr++) {
if (codeVal != "" && codelist[allowedCountryList[itr]] == codeVal && !hasCode) {
phoneVal = codeVal + phoneVal;
hasCode = true;
}
listofcountries[itr] = countryUniqueCode[allowedCountryList[itr]];
}
countryCodeProps.onlyCountries = listofcountries;
if ("live" == 'live') {
if (jQuery.inArray(defaultCountry, listofcountries) !== -1) {
initialCountry = defaultCountry;
} else if (ipBasedCurrentCountry !== null && ipBasedCurrentCountry != "null" && ipBasedCurrentCountry != "-" && jQuery.inArray(ipBasedCurrentCountry, listofcountries) != -1) { // No I18N
initialCountry = ipBasedCurrentCountry;
}
} else {
$("#PhoneNumber").val(phoneVal);
if ("false" == "true") {
$(keyIdConf).val(phoneVal); // No I18N
}
}
} else if ("live" == 'live') { // No I18N
if (defaultCountry != "") {
initialCountry = defaultCountry;
} else if (ipBasedCurrentCountry !== null && ipBasedCurrentCountry != "null" && ipBasedCurrentCountry != "-") { // No I18N
initialCountry = ipBasedCurrentCountry;
}
}
if ($(keyId).parents("ul").attr("elname") != "subFormFieldsCloneUl") {
countryCodeProps.initialCountry = initialCountry;
$(keyId).intlTelInput(countryCodeProps);
$(keyIdConf).intlTelInput(countryCodeProps); // No I18N
if ("live" == 'live') {
$(keyId).intlTelInput("setNumber", ""); // No I18N
}
if ("live" == 'edit' && "" != null && "" != "") {
$(keyId).intlTelInput("setCountry", ""); // No I18N
$(keyIdConf).intlTelInput("setCountry", ""); // No I18N
}
}
$(keyId).attr({
"initCountry": initialCountry,
"countryList": listofcountries
}); // No I18N
//$("#PhoneNumber") is used instead of variable keyId, since event get attached only to the last dom element instead of all elements.
setCountryCodePropsForFlds(("#" + "PhoneNumber"), isRtlEnabled); // No I18N
if ("false" == "true") {
setCountryCodePropsForFlds(("#" + "PhoneNumber" + "-reconf"), isRtlEnabled); // No I18N
}
}
</script>
</div>
<div class="clearBoth"></div>
</li>
<li isunique="false" class="tempFrmWrapper email small" elname="livefield-elem" comptype="9" id="Email-li" needdata="true" compname="Email" linkname="Email" isvisible="true" mandatory="true" page_no="1" page_link_name="Page" showlabel="true"
counteruid="" domain_option="0" need_reconf="false">
<label class="labelName" for="Email-arialabel">
<span>Email</span>
<em class="important" aria-label="Required">*</em>
</label>
<div class="subFrmFieldsHidden subFrmFieldsHiddenCont" style="display:none" elemname="fieldHiddenDiv"><em><svg class="icon icon-Denied-1-01">
<use xlink:href="#icon-rules-denied-01"></use>
</svg></em>
<span>N/A</span>
</div>
<div class="tempContDiv" elemname="fieldContentDiv" incwebhk_name="fieldContentDiv">
<span elname="livefield-email-elem"> <b class="inptCont">
<input inputmode="email" id="Email-arialabel" aria-describedby="hint-Email" onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="email" type="text" maxlength="255" name="Email" initalvalue="" value="" placeholder="">
</b>
<p class="errorMessage" elname="error" id="error-Email"></p>
</span>
</div>
<div class="clearBoth"></div>
</li>
<li class="tempFrmWrapper address addrlarge zfSelect2CustomCont" mode="live" elname="livefield-elem" comptype="8" needdata="true" id="Address-li" compname="Address" linkname="Address" isvisible="true" mandatory="true" page_no="1"
page_link_name="Page" showlabel="true" statefldtype="1" counteruid="">
<div class="arrowNav"></div>
<label class="labelName" id="Address-arialabel">
<span>Address</span>
<em class="important" aria-hidden="true">*</em>
</label>
<div class="subFrmFieldsHidden subFrmFieldsHiddenCont" style="display:none" elemname="fieldHiddenDiv"><em><svg class="icon icon-Denied-1-01">
<use xlink:href="#icon-rules-denied-01"></use>
</svg></em>
<span>N/A</span>
</div>
<div class="tempContDiv address" elemname="fieldContentDiv">
<div class="addrCont">
<!-- <input value=>-->
<span class="addOne" elname="compEachElem">
<span class="sr-only" elname="ariaReqSpan" id="ariarequired-Address0">Required</span>
<input aria-labelledby="Address-arialabel aria-showelemslabel-Address0 ariarequired-Address0" aria-describedby="hint-Address" name="Address" onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="address-line1" type="text"
maxlength="255" complink="Address_AddressLine1" value="" mandatory="true" placeholder="">
<!-- Display name of 'AddressLine1' component of 'Address' field. -->
<label class="formSubInfoText" elname="formSubInfoText" id="aria-showelemslabel-Address0">Street Address</label>
</span>
<!-- <input value=>-->
<span class="addOne" elname="compEachElem">
<input aria-labelledby="Address-arialabel aria-showelemslabel-Address1" aria-describedby="hint-Address" name="Address" onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="address-line2" type="text" maxlength="255"
complink="Address_AddressLine2" value="" mandatory="false" placeholder="">
<!-- Display name of 'AddressLine2' component of 'Address' field. -->
<label class="formSubInfoText" elname="formSubInfoText" id="aria-showelemslabel-Address1">Address Line 2</label>
</span>
<!-- <input value=>-->
<span class="flLeft addtwo" elname="compEachElem">
<span class="sr-only" elname="ariaReqSpan" id="ariarequired-Address2">Required</span>
<input aria-labelledby="Address-arialabel aria-showelemslabel-Address2 ariarequired-Address2" aria-describedby="hint-Address" name="Address" onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="address-level2" type="text"
maxlength="255" complink="Address_City" value="" mandatory="true" placeholder="">
<!-- Display name of 'City' component of 'Address' field. -->
<label class="formSubInfoText" elname="formSubInfoText" id="aria-showelemslabel-Address2">City</label>
</span>
<!-- <input value=>-->
<span class="flLeft addtwo" elname="compEachElem">
<span class="sr-only" elname="ariaReqSpan" id="ariarequired-Address3">Required</span>
<input aria-labelledby="Address-arialabel aria-showelemslabel-Address3 ariarequired-Address3" aria-describedby="hint-Address" name="Address" onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="address-level1" type="text"
maxlength="255" complink="Address_Region" value="" mandatory="true" placeholder="">
<!--</div>-->
<!-- Display name of 'Region' component of 'Address' field. -->
<label class="formSubInfoText" elname="formSubInfoText" id="aria-showelemslabel-Address3">State/Region/Province</label>
</span>
<!-- <input value=>-->
<span class="flLeft addtwo" elname="compEachElem">
<span class="sr-only" elname="ariaReqSpan" id="ariarequired-Address4">Required</span>
<input aria-labelledby="Address-arialabel aria-showelemslabel-Address4 ariarequired-Address4" aria-describedby="hint-Address" name="Address" onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="postal-code" type="text"
maxlength="255" complink="Address_ZipCode" value="" mandatory="true" placeholder="">
<!-- Display name of 'ZipCode' component of 'Address' field. -->
<label class="formSubInfoText" elname="formSubInfoText" id="aria-showelemslabel-Address4">Postal / Zip Code</label>
</span>
<!-- <input value=>-->
<span class="flLeft addtwo" elname="compEachElem">
<div class="form_selectBox">
<div class="selectArrow"></div>
<span class="sr-only" elname="ariaReqSpan" id="ariarequired-Address5">Required</span>
<select elname="dropdownElem" aria-labelledby="Address-arialabel aria-showelemslabel-Address5 ariarequired-Address5" aria-describedby="hint-Address" onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="country"
name="Address" complink="Address_Country" id="Address_Country" mandatory="true" tabindex="-1" class="select2-hidden-accessible" aria-hidden="true">
<option value="-Select-">-Select-</option>
<option value="Åland Islands" ctrycode="103" lwrvalue="åland islands">Åland Islands</option>
<option value="Afghanistan" ctrycode="101" lwrvalue="afghanistan">Afghanistan</option>
<option value="Akrotiri" ctrycode="102" lwrvalue="akrotiri">Akrotiri</option>
<option value="Albania" ctrycode="104" lwrvalue="albania">Albania</option>
<option value="Algeria" ctrycode="105" lwrvalue="algeria">Algeria</option>
<option value="American Samoa" ctrycode="106" lwrvalue="american samoa">American Samoa</option>
<option value="Andorra" ctrycode="107" lwrvalue="andorra">Andorra</option>
<option value="Angola" ctrycode="108" lwrvalue="angola">Angola</option>
<option value="Anguilla" ctrycode="109" lwrvalue="anguilla">Anguilla</option>
<option value="Antarctica" ctrycode="110" lwrvalue="antarctica">Antarctica</option>
<option value="Antigua and Barbuda" ctrycode="111" lwrvalue="antigua and barbuda">Antigua and Barbuda</option>
<option value="Argentina" ctrycode="112" lwrvalue="argentina">Argentina</option>
<option value="Armenia" ctrycode="113" lwrvalue="armenia">Armenia</option>
<option value="Aruba" ctrycode="114" lwrvalue="aruba">Aruba</option>
<option value="Ashmore and Cartier Islands" ctrycode="115" lwrvalue="ashmore and cartier islands">Ashmore and Cartier Islands</option>
<option value="Australia" ctrycode="116" lwrvalue="australia">Australia</option>
<option value="Austria" ctrycode="117" lwrvalue="austria">Austria</option>
<option value="Azerbaijan" ctrycode="118" lwrvalue="azerbaijan">Azerbaijan</option>
<option value="Bahrain" ctrycode="120" lwrvalue="bahrain">Bahrain</option>
<option value="Bangladesh" ctrycode="121" lwrvalue="bangladesh">Bangladesh</option>
<option value="Barbados" ctrycode="122" lwrvalue="barbados">Barbados</option>
<option value="Bassas Da India" ctrycode="123" lwrvalue="bassas da india">Bassas Da India</option>
<option value="Belarus" ctrycode="124" lwrvalue="belarus">Belarus</option>
<option value="Belgium" ctrycode="125" lwrvalue="belgium">Belgium</option>
<option value="Belize" ctrycode="126" lwrvalue="belize">Belize</option>
<option value="Benin" ctrycode="127" lwrvalue="benin">Benin</option>
<option value="Bermuda" ctrycode="128" lwrvalue="bermuda">Bermuda</option>
<option value="Bhutan" ctrycode="129" lwrvalue="bhutan">Bhutan</option>
<option value="Bolivia" ctrycode="130" lwrvalue="bolivia">Bolivia</option>
<option value="Bosnia and Herzegovina" ctrycode="131" lwrvalue="bosnia and herzegovina">Bosnia and Herzegovina</option>
<option value="Botswana" ctrycode="132" lwrvalue="botswana">Botswana</option>
<option value="Bouvet Island" ctrycode="133" lwrvalue="bouvet island">Bouvet Island</option>
<option value="Brazil" ctrycode="134" lwrvalue="brazil">Brazil</option>
<option value="British Indian Ocean Territory" ctrycode="135" lwrvalue="british indian ocean territory">British Indian Ocean Territory</option>
<option value="British Virgin Islands" ctrycode="136" lwrvalue="british virgin islands">British Virgin Islands</option>
<option value="Brunei" ctrycode="137" lwrvalue="brunei">Brunei</option>
<option value="Bulgaria" ctrycode="138" lwrvalue="bulgaria">Bulgaria</option>
<option value="Burkina Faso" ctrycode="139" lwrvalue="burkina faso">Burkina Faso</option>
<option value="Burma" ctrycode="140" lwrvalue="burma">Burma</option>
<option value="Burundi" ctrycode="141" lwrvalue="burundi">Burundi</option>
<option value="Cambodia" ctrycode="142" lwrvalue="cambodia">Cambodia</option>
<option value="Cameroon" ctrycode="143" lwrvalue="cameroon">Cameroon</option>
<option value="Canada" ctrycode="144" lwrvalue="canada">Canada</option>
<option value="Cape Verde" ctrycode="145" lwrvalue="cape verde">Cape Verde</option>
<option value="Caribbean Netherlands" ctrycode="146" lwrvalue="caribbean netherlands">Caribbean Netherlands</option>
<option value="Cayman Islands" ctrycode="147" lwrvalue="cayman islands">Cayman Islands</option>
<option value="Central African Republic" ctrycode="148" lwrvalue="central african republic">Central African Republic</option>
<option value="Chad" ctrycode="149" lwrvalue="chad">Chad</option>
<option value="Chile" ctrycode="150" lwrvalue="chile">Chile</option>
<option value="China" ctrycode="151" lwrvalue="china">China</option>
<option value="Christmas Island" ctrycode="152" lwrvalue="christmas island">Christmas Island</option>
<option value="Clipperton Island" ctrycode="153" lwrvalue="clipperton island">Clipperton Island</option>
<option value="Cocos (Keeling) Islands" ctrycode="154" lwrvalue="cocos (keeling) islands">Cocos (Keeling) Islands</option>
<option value="Colombia" ctrycode="155" lwrvalue="colombia">Colombia</option>
<option value="Comoros" ctrycode="156" lwrvalue="comoros">Comoros</option>
<option value="Cook Islands" ctrycode="159" lwrvalue="cook islands">Cook Islands</option>
<option value="Coral Sea Islands" ctrycode="160" lwrvalue="coral sea islands">Coral Sea Islands</option>
<option value="Costa Rica" ctrycode="161" lwrvalue="costa rica">Costa Rica</option>
<option value="Cote D'Ivoire" ctrycode="162" lwrvalue="cote d'ivoire">Cote D'Ivoire</option>
<option value="Croatia" ctrycode="163" lwrvalue="croatia">Croatia</option>
<option value="Cuba" ctrycode="164" lwrvalue="cuba">Cuba</option>
<option value="Curaçao" ctrycode="165" lwrvalue="curaçao">Curaçao</option>
<option value="Cyprus" ctrycode="166" lwrvalue="cyprus">Cyprus</option>
<option value="Czech Republic" ctrycode="167" lwrvalue="czech republic">Czech Republic</option>
<option value="Democratic Republic of the Congo" ctrycode="157" lwrvalue="democratic republic of the congo">Democratic Republic of the Congo</option>
<option value="Denmark" ctrycode="168" lwrvalue="denmark">Denmark</option>
<option value="Dhekelia" ctrycode="169" lwrvalue="dhekelia">Dhekelia</option>
<option value="Djibouti" ctrycode="170" lwrvalue="djibouti">Djibouti</option>
<option value="Dominica" ctrycode="171" lwrvalue="dominica">Dominica</option>
<option value="Dominican Republic" ctrycode="172" lwrvalue="dominican republic">Dominican Republic</option>
<option value="Ecuador" ctrycode="173" lwrvalue="ecuador">Ecuador</option>
<option value="Egypt" ctrycode="174" lwrvalue="egypt">Egypt</option>
<option value="El Salvador" ctrycode="175" lwrvalue="el salvador">El Salvador</option>
<option value="Equatorial Guinea" ctrycode="176" lwrvalue="equatorial guinea">Equatorial Guinea</option>
<option value="Eritrea" ctrycode="177" lwrvalue="eritrea">Eritrea</option>
<option value="Estonia" ctrycode="178" lwrvalue="estonia">Estonia</option>
<option value="Ethiopia" ctrycode="179" lwrvalue="ethiopia">Ethiopia</option>
<option value="Europa Island" ctrycode="180" lwrvalue="europa island">Europa Island</option>
<option value="Falkland Islands (Islas Malvinas)" ctrycode="181" lwrvalue="falkland islands (islas malvinas)">Falkland Islands (Islas Malvinas)</option>
<option value="Faroe Islands" ctrycode="182" lwrvalue="faroe islands">Faroe Islands</option>
<option value="Federated States of Micronesia" ctrycode="258" lwrvalue="federated states of micronesia">Federated States of Micronesia</option>
<option value="Fiji" ctrycode="183" lwrvalue="fiji">Fiji</option>
<option value="Finland" ctrycode="184" lwrvalue="finland">Finland</option>
<option value="France" ctrycode="185" lwrvalue="france">France</option>
<option value="French Guiana" ctrycode="186" lwrvalue="french guiana">French Guiana</option>
<option value="French Polynesia" ctrycode="187" lwrvalue="french polynesia">French Polynesia</option>
<option value="French Southern and Antarctic Lands" ctrycode="188" lwrvalue="french southern and antarctic lands">French Southern and Antarctic Lands</option>
<option value="Gabon" ctrycode="189" lwrvalue="gabon">Gabon</option>
<option value="Gaza Strip" ctrycode="191" lwrvalue="gaza strip">Gaza Strip</option>
<option value="Georgia" ctrycode="192" lwrvalue="georgia">Georgia</option>
<option value="Germany" ctrycode="193" lwrvalue="germany">Germany</option>
<option value="Ghana" ctrycode="194" lwrvalue="ghana">Ghana</option>
<option value="Gibraltar" ctrycode="195" lwrvalue="gibraltar">Gibraltar</option>
<option value="Glorioso Islands" ctrycode="196" lwrvalue="glorioso islands">Glorioso Islands</option>
<option value="Greece" ctrycode="197" lwrvalue="greece">Greece</option>
<option value="Greenland" ctrycode="198" lwrvalue="greenland">Greenland</option>
<option value="Grenada" ctrycode="199" lwrvalue="grenada">Grenada</option>
<option value="Guadeloupe" ctrycode="200" lwrvalue="guadeloupe">Guadeloupe</option>
<option value="Guam" ctrycode="201" lwrvalue="guam">Guam</option>
<option value="Guatemala" ctrycode="202" lwrvalue="guatemala">Guatemala</option>
<option value="Guernsey" ctrycode="203" lwrvalue="guernsey">Guernsey</option>
<option value="Guinea" ctrycode="204" lwrvalue="guinea">Guinea</option>
<option value="Guinea-bissau" ctrycode="205" lwrvalue="guinea-bissau">Guinea-bissau</option>
<option value="Guyana" ctrycode="206" lwrvalue="guyana">Guyana</option>
<option value="Haiti" ctrycode="207" lwrvalue="haiti">Haiti</option>
<option value="Heard Island and Mcdonald Islands" ctrycode="208" lwrvalue="heard island and mcdonald islands">Heard Island and Mcdonald Islands</option>
<option value="Holy See (Vatican City)" ctrycode="209" lwrvalue="holy see (vatican city)">Holy See (Vatican City)</option>
<option value="Honduras" ctrycode="210" lwrvalue="honduras">Honduras</option>
<option value="Hong Kong" ctrycode="211" lwrvalue="hong kong">Hong Kong</option>
<option value="Hungary" ctrycode="212" lwrvalue="hungary">Hungary</option>
<option value="Iceland" ctrycode="213" lwrvalue="iceland">Iceland</option>
<option value="India" ctrycode="214" lwrvalue="india">India</option>
<option value="Indonesia" ctrycode="215" lwrvalue="indonesia">Indonesia</option>
<option value="Iran" ctrycode="216" lwrvalue="iran">Iran</option>
<option value="Iraq" ctrycode="217" lwrvalue="iraq">Iraq</option>
<option value="Ireland" ctrycode="218" lwrvalue="ireland">Ireland</option>
<option value="Isle of Man" ctrycode="219" lwrvalue="isle of man">Isle of Man</option>
<option value="Israel" ctrycode="220" lwrvalue="israel">Israel</option>
<option value="Italy" ctrycode="221" lwrvalue="italy">Italy</option>
<option value="Jamaica" ctrycode="222" lwrvalue="jamaica">Jamaica</option>
<option value="Jan Mayen" ctrycode="223" lwrvalue="jan mayen">Jan Mayen</option>
<option value="Japan" ctrycode="224" lwrvalue="japan">Japan</option>
<option value="Jersey" ctrycode="225" lwrvalue="jersey">Jersey</option>
<option value="Jordan" ctrycode="226" lwrvalue="jordan">Jordan</option>
<option value="Juan De Nova Island" ctrycode="227" lwrvalue="juan de nova island">Juan De Nova Island</option>
<option value="Kazakhstan" ctrycode="228" lwrvalue="kazakhstan">Kazakhstan</option>
<option value="Kenya" ctrycode="229" lwrvalue="kenya">Kenya</option>
<option value="Kiribati" ctrycode="230" lwrvalue="kiribati">Kiribati</option>
<option value="Kosovo" ctrycode="368" lwrvalue="kosovo">Kosovo</option>
<option value="Kuwait" ctrycode="233" lwrvalue="kuwait">Kuwait</option>
<option value="Kyrgyzstan" ctrycode="234" lwrvalue="kyrgyzstan">Kyrgyzstan</option>
<option value="Laos" ctrycode="235" lwrvalue="laos">Laos</option>
<option value="Latvia" ctrycode="236" lwrvalue="latvia">Latvia</option>
<option value="Lebanon" ctrycode="237" lwrvalue="lebanon">Lebanon</option>
<option value="Lesotho" ctrycode="238" lwrvalue="lesotho">Lesotho</option>
<option value="Liberia" ctrycode="239" lwrvalue="liberia">Liberia</option>
<option value="Libya" ctrycode="240" lwrvalue="libya">Libya</option>
<option value="Liechtenstein" ctrycode="241" lwrvalue="liechtenstein">Liechtenstein</option>
<option value="Lithuania" ctrycode="242" lwrvalue="lithuania">Lithuania</option>
<option value="Luxembourg" ctrycode="243" lwrvalue="luxembourg">Luxembourg</option>
<option value="Macau" ctrycode="244" lwrvalue="macau">Macau</option>
<option value="Macedonia" ctrycode="245" lwrvalue="macedonia">Macedonia</option>
<option value="Madagascar" ctrycode="246" lwrvalue="madagascar">Madagascar</option>
<option value="Malawi" ctrycode="247" lwrvalue="malawi">Malawi</option>
<option value="Malaysia" ctrycode="248" lwrvalue="malaysia">Malaysia</option>
<option value="Maldives" ctrycode="249" lwrvalue="maldives">Maldives</option>
<option value="Mali" ctrycode="250" lwrvalue="mali">Mali</option>
<option value="Malta" ctrycode="251" lwrvalue="malta">Malta</option>
<option value="Marshall Islands" ctrycode="252" lwrvalue="marshall islands">Marshall Islands</option>
<option value="Martinique" ctrycode="253" lwrvalue="martinique">Martinique</option>
<option value="Mauritania" ctrycode="254" lwrvalue="mauritania">Mauritania</option>
<option value="Mauritius" ctrycode="255" lwrvalue="mauritius">Mauritius</option>
<option value="Mayotte" ctrycode="256" lwrvalue="mayotte">Mayotte</option>
<option value="Mexico" ctrycode="257" lwrvalue="mexico">Mexico</option>
<option value="Moldova" ctrycode="259" lwrvalue="moldova">Moldova</option>
<option value="Monaco" ctrycode="260" lwrvalue="monaco">Monaco</option>
<option value="Mongolia" ctrycode="261" lwrvalue="mongolia">Mongolia</option>
<option value="Montenegro" ctrycode="262" lwrvalue="montenegro">Montenegro</option>
<option value="Montserrat" ctrycode="263" lwrvalue="montserrat">Montserrat</option>
<option value="Morocco" ctrycode="264" lwrvalue="morocco">Morocco</option>
<option value="Mozambique" ctrycode="265" lwrvalue="mozambique">Mozambique</option>
<option value="Myanmar" ctrycode="266" lwrvalue="myanmar">Myanmar</option>
<option value="Namibia" ctrycode="267" lwrvalue="namibia">Namibia</option>
<option value="Nauru" ctrycode="268" lwrvalue="nauru">Nauru</option>
<option value="Navassa Island" ctrycode="269" lwrvalue="navassa island">Navassa Island</option>
<option value="Nepal" ctrycode="270" lwrvalue="nepal">Nepal</option>
<option value="Netherlands" ctrycode="271" lwrvalue="netherlands">Netherlands</option>
<option value="Netherlands Antilles" ctrycode="272" lwrvalue="netherlands antilles">Netherlands Antilles</option>
<option value="New Caledonia" ctrycode="273" lwrvalue="new caledonia">New Caledonia</option>
<option value="New Zealand" ctrycode="274" lwrvalue="new zealand">New Zealand</option>
<option value="Nicaragua" ctrycode="275" lwrvalue="nicaragua">Nicaragua</option>
<option value="Niger" ctrycode="276" lwrvalue="niger">Niger</option>
<option value="Nigeria" ctrycode="277" lwrvalue="nigeria">Nigeria</option>
<option value="Niue" ctrycode="278" lwrvalue="niue">Niue</option>
<option value="Norfolk Island" ctrycode="279" lwrvalue="norfolk island">Norfolk Island</option>
<option value="North Korea" ctrycode="231" lwrvalue="north korea">North Korea</option>
<option value="Northern Mariana Islands" ctrycode="280" lwrvalue="northern mariana islands">Northern Mariana Islands</option>
<option value="Norway" ctrycode="281" lwrvalue="norway">Norway</option>
<option value="Oman" ctrycode="282" lwrvalue="oman">Oman</option>
<option value="Pakistan" ctrycode="283" lwrvalue="pakistan">Pakistan</option>
<option value="Palau" ctrycode="284" lwrvalue="palau">Palau</option>
<option value="Palestine" ctrycode="285" lwrvalue="palestine">Palestine</option>
<option value="Panama" ctrycode="286" lwrvalue="panama">Panama</option>
<option value="Papua New Guinea" ctrycode="287" lwrvalue="papua new guinea">Papua New Guinea</option>
<option value="Paracel Islands" ctrycode="288" lwrvalue="paracel islands">Paracel Islands</option>
<option value="Paraguay" ctrycode="289" lwrvalue="paraguay">Paraguay</option>
<option value="Peru" ctrycode="290" lwrvalue="peru">Peru</option>
<option value="Philippines" ctrycode="291" lwrvalue="philippines">Philippines</option>
<option value="Pitcairn Islands" ctrycode="292" lwrvalue="pitcairn islands">Pitcairn Islands</option>
<option value="Poland" ctrycode="293" lwrvalue="poland">Poland</option>
<option value="Portugal" ctrycode="294" lwrvalue="portugal">Portugal</option>
<option value="Puerto Rico" ctrycode="295" lwrvalue="puerto rico">Puerto Rico</option>
<option value="Qatar" ctrycode="296" lwrvalue="qatar">Qatar</option>
<option value="Republic of the Congo" ctrycode="158" lwrvalue="republic of the congo">Republic of the Congo</option>
<option value="Reunion" ctrycode="297" lwrvalue="reunion">Reunion</option>
<option value="Romania" ctrycode="298" lwrvalue="romania">Romania</option>
<option value="Russia" ctrycode="299" lwrvalue="russia">Russia</option>
<option value="Rwanda" ctrycode="300" lwrvalue="rwanda">Rwanda</option>
<option value="Saint Barthélemy" ctrycode="301" lwrvalue="saint barthã©lemy">Saint Barthélemy</option>
<option value="Saint Helena" ctrycode="302" lwrvalue="saint helena">Saint Helena</option>
<option value="Saint Kitts and Nevis" ctrycode="303" lwrvalue="saint kitts and nevis">Saint Kitts and Nevis</option>
<option value="Saint Lucia" ctrycode="304" lwrvalue="saint lucia">Saint Lucia</option>
<option value="Saint Martin" ctrycode="305" lwrvalue="saint martin">Saint Martin</option>
<option value="Saint Pierre and Miquelon" ctrycode="306" lwrvalue="saint pierre and miquelon">Saint Pierre and Miquelon</option>
<option value="Saint Vincent and the Grenadines" ctrycode="307" lwrvalue="saint vincent and the grenadines">Saint Vincent and the Grenadines</option>
<option value="Samoa" ctrycode="308" lwrvalue="samoa">Samoa</option>
<option value="San Marino" ctrycode="309" lwrvalue="san marino">San Marino</option>
<option value="Sao Tome and Principe" ctrycode="310" lwrvalue="sao tome and principe">Sao Tome and Principe</option>
<option value="Saudi Arabia" ctrycode="311" lwrvalue="saudi arabia">Saudi Arabia</option>
<option value="Senegal" ctrycode="312" lwrvalue="senegal">Senegal</option>
<option value="Serbia" ctrycode="313" lwrvalue="serbia">Serbia</option>
<option value="Seychelles" ctrycode="314" lwrvalue="seychelles">Seychelles</option>
<option value="Sierra Leone" ctrycode="315" lwrvalue="sierra leone">Sierra Leone</option>
<option value="Singapore" ctrycode="316" lwrvalue="singapore">Singapore</option>
<option value="Sint Maarten" ctrycode="317" lwrvalue="sint maarten">Sint Maarten</option>
<option value="Slovakia" ctrycode="318" lwrvalue="slovakia">Slovakia</option>
<option value="Slovenia" ctrycode="319" lwrvalue="slovenia">Slovenia</option>
<option value="Solomon Islands" ctrycode="320" lwrvalue="solomon islands">Solomon Islands</option>
<option value="Somalia" ctrycode="321" lwrvalue="somalia">Somalia</option>
<option value="South Africa" ctrycode="322" lwrvalue="south africa">South Africa</option>
<option value="South Georgia and the South Sandwich Islands" ctrycode="323" lwrvalue="south georgia and the south sandwich islands">South Georgia and the South Sandwich Islands</option>
<option value="South Korea" ctrycode="232" lwrvalue="south korea">South Korea</option>
<option value="South Sudan" ctrycode="324" lwrvalue="south sudan">South Sudan</option>
<option value="Spain" ctrycode="325" lwrvalue="spain">Spain</option>
<option value="Spratly Islands" ctrycode="326" lwrvalue="spratly islands">Spratly Islands</option>
<option value="Sri Lanka" ctrycode="327" lwrvalue="sri lanka">Sri Lanka</option>
<option value="Sudan" ctrycode="328" lwrvalue="sudan">Sudan</option>
<option value="Suriname" ctrycode="329" lwrvalue="suriname">Suriname</option>
<option value="Svalbard" ctrycode="330" lwrvalue="svalbard">Svalbard</option>
<option value="Swaziland" ctrycode="331" lwrvalue="swaziland">Swaziland</option>
<option value="Sweden" ctrycode="332" lwrvalue="sweden">Sweden</option>
<option value="Switzerland" ctrycode="333" lwrvalue="switzerland">Switzerland</option>
<option value="Syria" ctrycode="334" lwrvalue="syria">Syria</option>
<option value="Taiwan" ctrycode="335" lwrvalue="taiwan">Taiwan</option>
<option value="Tajikistan" ctrycode="336" lwrvalue="tajikistan">Tajikistan</option>
<option value="Tanzania" ctrycode="337" lwrvalue="tanzania">Tanzania</option>
<option value="Thailand" ctrycode="338" lwrvalue="thailand">Thailand</option>
<option value="The Bahamas" ctrycode="119" lwrvalue="the bahamas">The Bahamas</option>
<option value="The Gambia" ctrycode="190" lwrvalue="the gambia">The Gambia</option>
<option value="Timor-leste" ctrycode="339" lwrvalue="timor-leste">Timor-leste</option>
<option value="Togo" ctrycode="340" lwrvalue="togo">Togo</option>
<option value="Tokelau" ctrycode="341" lwrvalue="tokelau">Tokelau</option>
<option value="Tonga" ctrycode="342" lwrvalue="tonga">Tonga</option>
<option value="Trinidad and Tobago" ctrycode="343" lwrvalue="trinidad and tobago">Trinidad and Tobago</option>
<option value="Tromelin Island" ctrycode="344" lwrvalue="tromelin island">Tromelin Island</option>
<option value="Tunisia" ctrycode="345" lwrvalue="tunisia">Tunisia</option>
<option value="Turkey" ctrycode="346" lwrvalue="turkey">Turkey</option>
<option value="Turkmenistan" ctrycode="347" lwrvalue="turkmenistan">Turkmenistan</option>
<option value="Turks and Caicos Islands" ctrycode="348" lwrvalue="turks and caicos islands">Turks and Caicos Islands</option>
<option value="Tuvalu" ctrycode="349" lwrvalue="tuvalu">Tuvalu</option>
<option value="Uganda" ctrycode="350" lwrvalue="uganda">Uganda</option>
<option value="Ukraine" ctrycode="351" lwrvalue="ukraine">Ukraine</option>
<option value="United Arab Emirates" ctrycode="352" lwrvalue="united arab emirates">United Arab Emirates</option>
<option value="United Kingdom" ctrycode="353" lwrvalue="united kingdom">United Kingdom</option>
<option value="United States" ctrycode="354" lwrvalue="united states" selected="true">United States</option>
<option value="Uruguay" ctrycode="355" lwrvalue="uruguay">Uruguay</option>
<option value="Uzbekistan" ctrycode="356" lwrvalue="uzbekistan">Uzbekistan</option>
<option value="Vanuatu" ctrycode="357" lwrvalue="vanuatu">Vanuatu</option>
<option value="Venezuela" ctrycode="358" lwrvalue="venezuela">Venezuela</option>
<option value="Vietnam" ctrycode="359" lwrvalue="vietnam">Vietnam</option>
<option value="Virgin Islands" ctrycode="360" lwrvalue="virgin islands">Virgin Islands</option>
<option value="Wake Island" ctrycode="361" lwrvalue="wake island">Wake Island</option>
<option value="Wallis and Futuna" ctrycode="362" lwrvalue="wallis and futuna">Wallis and Futuna</option>
<option value="West Bank" ctrycode="363" lwrvalue="west bank">West Bank</option>
<option value="Western Sahara" ctrycode="364" lwrvalue="western sahara">Western Sahara</option>
<option value="Yemen" ctrycode="365" lwrvalue="yemen">Yemen</option>
<option value="Zambia" ctrycode="366" lwrvalue="zambia">Zambia</option>
<option value="Zimbabwe" ctrycode="367" lwrvalue="zimbabwe">Zimbabwe</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" style="width: 228.875px;"><span class="selection"><span class="select2-selection select2-selection--single select2FormCont" role="combobox"
aria-haspopup="true" aria-expanded="false" tabindex="0" aria-labelledby="select2-Address_Country-container"><span class="select2-selection__rendered" id="select2-Address_Country-container" title="United States">
<div class="select2FormFont">United States</div>
</span><span class="select2-selection__arrow select2FormArrow" role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
</div><!-- Display name of 'Country' component of 'Address' field. -->
<label class="formSubInfoText formSubInfoAlign" elname="formSubInfoText" id="aria-showelemslabel-Address5">Country</label>
</span>
<div class="clearBoth"></div>
<p class="errorMessage" elname="error" id="error-Address"></p>
</div>
</div>
<div class="clearBoth"></div>
<script type="module">
$(function() {
var mode = "live"; // No I18N
if (mode == "edit") { // No I18N
var selectedCountry = ""; // No I18N
var selectedCountryNonEncoded = ""; // No I18N
var compname = "Address"; //No I18N
var linkname;
if (compname.indexOf("_") != -1) {
var splittedArr = compname.split("_");
linkname = splittedArr[0];
} else {
linkname = compname;
}
var countryDropdown = $("#Address-li").find('select[complink=' + linkname + ZFFormField.ADDRESS.COUNTRY.KEY + ']');
if (selectedCountry.length > 0 && (typeof($(countryDropdown).find('option:selected').val()) == 'undefined' || $(countryDropdown).find('option:selected').val().toLowerCase() != selectedCountryNonEncoded.toLowerCase())) { // No I18N
$(countryDropdown).append($("<option></option>").attr("value", selectedCountryNonEncoded).html(selectedCountry).hide()); // No I18N
$(countryDropdown).val(selectedCountryNonEncoded).change();
}
}
});
</script>
</li>
<li class="zfcheckbox tempFrmWrapper oneColumns " minchoices="1" elname="livefield-elem" comptype="14" needdata="true" id="Checkbox-li" compname="Checkbox" linkname="Checkbox" isvisible="true" mandatory="true" page_no="1"
page_link_name="Page" choice_type="checkbox" counteruid="">
<label id="Checkbox-arialabel" class="labelName"><span>Race</span>
<em class="important" aria-label="Required">*</em>
</label>
<div class="subFrmFieldsHidden subFrmFieldsHiddenCont" style="display:none" elemname="fieldHiddenDiv"><em><svg class="icon icon-Denied-1-01">
<use xlink:href="#icon-rules-denied-01"></use>
</svg></em>
<span>N/A</span>
</div>
<div class="tempContDiv" elemname="fieldContentDiv">
<div class="overflow customCheckBox" role="group" aria-labelledby="Checkbox-arialabel">
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" aria-describedby="Checkbox-arialabel hint-Checkbox" aria-label="American Indian or Alaska Native" type="checkbox" id="Checkbox_1"
class="checkBoxType" name="Checkbox" elname="Checkbox" value="American Indian or Alaska Native" textassign_val="" emailassign_val="" formula_val="" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);">
<label for="Checkbox_1" aria-hidden="true" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">American Indian or Alaska Native</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" aria-describedby="Checkbox-arialabel hint-Checkbox" aria-label="Asian" type="checkbox" id="Checkbox_2" class="checkBoxType" name="Checkbox"
elname="Checkbox" value="Asian" textassign_val="" emailassign_val="" formula_val="" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);">
<label for="Checkbox_2" aria-hidden="true" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">Asian</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" aria-describedby="Checkbox-arialabel hint-Checkbox" aria-label="Black/African American" type="checkbox" id="Checkbox_3" class="checkBoxType"
name="Checkbox" elname="Checkbox" value="Black/African American" textassign_val="" emailassign_val="" formula_val="" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);">
<label for="Checkbox_3" aria-hidden="true" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">Black/African American</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" aria-describedby="Checkbox-arialabel hint-Checkbox" aria-label="Native Hawaiian or Other Pacific Islander" type="checkbox" id="Checkbox_4"
class="checkBoxType" name="Checkbox" elname="Checkbox" value="Native Hawaiian or Other Pacific Islander" textassign_val="" emailassign_val="" formula_val="" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);">
<label for="Checkbox_4" aria-hidden="true" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">Native Hawaiian or Other Pacific Islander</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" aria-describedby="Checkbox-arialabel hint-Checkbox" aria-label="White" type="checkbox" id="Checkbox_5" class="checkBoxType" name="Checkbox"
elname="Checkbox" value="White" textassign_val="" emailassign_val="" formula_val="" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);">
<label for="Checkbox_5" aria-hidden="true" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">White</em>
</label> </span>
<div class="clearBoth"></div>
</div>
<p class="errorMessage" elname="error" id="error-Checkbox"></p>
</div>
<div class="clearBoth"></div>
</li>
<li class="zfcheckbox tempFrmWrapper oneColumns " minchoices="1" maxchoices="1" elname="livefield-elem" comptype="14" needdata="true" id="Checkbox1-li" compname="Checkbox1" linkname="Checkbox1" isvisible="true" mandatory="true" page_no="1"
page_link_name="Page" choice_type="checkbox" counteruid="">
<label id="Checkbox1-arialabel" class="labelName"><span>Ethnicity</span>
<em class="important" aria-label="Required">*</em>
</label>
<div class="subFrmFieldsHidden subFrmFieldsHiddenCont" style="display:none" elemname="fieldHiddenDiv"><em><svg class="icon icon-Denied-1-01">
<use xlink:href="#icon-rules-denied-01"></use>
</svg></em>
<span>N/A</span>
</div>
<div class="tempContDiv" elemname="fieldContentDiv">
<div class="overflow customCheckBox" role="group" aria-labelledby="Checkbox1-arialabel">
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" aria-describedby="Checkbox1-arialabel hint-Checkbox1" aria-label="Hispanic or Latino" type="checkbox" id="Checkbox1_1" class="checkBoxType"
name="Checkbox1" elname="Checkbox1" value="Hispanic or Latino" textassign_val="" emailassign_val="" formula_val="" onchange="ZFLive.checkMaxChoiceLimit(this);">
<label for="Checkbox1_1" aria-hidden="true" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">Hispanic or Latino</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" aria-describedby="Checkbox1-arialabel hint-Checkbox1" aria-label="Not Hispanic or Latino" type="checkbox" id="Checkbox1_2" class="checkBoxType"
name="Checkbox1" elname="Checkbox1" value="Not Hispanic or Latino" textassign_val="" emailassign_val="" formula_val="" onchange="ZFLive.checkMaxChoiceLimit(this);">
<label for="Checkbox1_2" aria-hidden="true" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">Not Hispanic or Latino</em>
</label> </span>
<div class="clearBoth"></div>
</div>
<p class="errorMessage" elname="error" id="error-Checkbox1"></p>
</div>
<div class="clearBoth"></div>
</li>
<li class="zfcheckbox tempFrmWrapper oneColumns " minchoices="1" maxchoices="1" elname="livefield-elem" comptype="14" needdata="true" id="Checkbox2-li" compname="Checkbox2" linkname="Checkbox2" isvisible="true" mandatory="true" page_no="1"
page_link_name="Page" choice_type="checkbox" counteruid="">
<label id="Checkbox2-arialabel" class="labelName"><span>Gender</span>
<em class="important" aria-label="Required">*</em>
</label>
<div class="subFrmFieldsHidden subFrmFieldsHiddenCont" style="display:none" elemname="fieldHiddenDiv"><em><svg class="icon icon-Denied-1-01">
<use xlink:href="#icon-rules-denied-01"></use>
</svg></em>
<span>N/A</span>
</div>
<div class="tempContDiv" elemname="fieldContentDiv">
<div class="overflow customCheckBox" role="group" aria-labelledby="Checkbox2-arialabel">
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" aria-describedby="Checkbox2-arialabel hint-Checkbox2" aria-label="Female" type="checkbox" id="Checkbox2_1" class="checkBoxType" name="Checkbox2"
elname="Checkbox2" value="Female" textassign_val="" emailassign_val="" formula_val="" onchange="ZFLive.checkMaxChoiceLimit(this);">
<label for="Checkbox2_1" aria-hidden="true" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">Female</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" aria-describedby="Checkbox2-arialabel hint-Checkbox2" aria-label="Male" type="checkbox" id="Checkbox2_2" class="checkBoxType" name="Checkbox2"
elname="Checkbox2" value="Male" textassign_val="" emailassign_val="" formula_val="" onchange="ZFLive.checkMaxChoiceLimit(this);">
<label for="Checkbox2_2" aria-hidden="true" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">Male</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" aria-describedby="Checkbox2-arialabel hint-Checkbox2" aria-label="Other" type="checkbox" id="Checkbox2_3" class="checkBoxType" name="Checkbox2"
elname="Checkbox2" value="Other" textassign_val="" emailassign_val="" formula_val="" onchange="ZFLive.checkMaxChoiceLimit(this);">
<label for="Checkbox2_3" aria-hidden="true" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">Other</em>
</label> </span>
<div class="clearBoth"></div>
</div>
<p class="errorMessage" elname="error" id="error-Checkbox2"></p>
</div>
<div class="clearBoth"></div>
</li>
<li class="zfcheckbox tempFrmWrapper oneColumns " minchoices="1" maxchoices="1" elname="livefield-elem" comptype="14" needdata="true" id="Checkbox3-li" compname="Checkbox3" linkname="Checkbox3" isvisible="true" mandatory="true" page_no="1"
page_link_name="Page" choice_type="checkbox" counteruid="">
<label id="Checkbox3-arialabel" class="labelName"><span>Do you consider yourself a person with a disability?</span>
<em class="important" aria-label="Required">*</em>
</label>
<div class="subFrmFieldsHidden subFrmFieldsHiddenCont" style="display:none" elemname="fieldHiddenDiv"><em><svg class="icon icon-Denied-1-01">
<use xlink:href="#icon-rules-denied-01"></use>
</svg></em>
<span>N/A</span>
</div>
<div class="tempContDiv" elemname="fieldContentDiv">
<div class="overflow customCheckBox" role="group" aria-labelledby="Checkbox3-arialabel">
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" aria-describedby="Checkbox3-arialabel hint-Checkbox3" aria-label="Yes" type="checkbox" id="Checkbox3_1" class="checkBoxType" name="Checkbox3"
elname="Checkbox3" value="Yes" textassign_val="" emailassign_val="" formula_val="" onchange="ZFLive.checkMaxChoiceLimit(this);">
<label for="Checkbox3_1" aria-hidden="true" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">Yes</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" aria-describedby="Checkbox3-arialabel hint-Checkbox3" aria-label="No" type="checkbox" id="Checkbox3_2" class="checkBoxType" name="Checkbox3"
elname="Checkbox3" value="No" textassign_val="" emailassign_val="" formula_val="" onchange="ZFLive.checkMaxChoiceLimit(this);">
<label for="Checkbox3_2" aria-hidden="true" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">No</em>
</label> </span>
<div class="clearBoth"></div>
</div>
<p class="errorMessage" elname="error" id="error-Checkbox3"></p>
</div>
<div class="clearBoth"></div>
</li>
<li class="zfcheckbox tempFrmWrapper oneColumns " minchoices="1" maxchoices="1" elname="livefield-elem" comptype="14" needdata="true" id="Checkbox4-li" compname="Checkbox4" linkname="Checkbox4" isvisible="true" mandatory="true" page_no="1"
page_link_name="Page" choice_type="checkbox" counteruid="">
<label id="Checkbox4-arialabel" class="labelName"><span>Military Status</span>
<em class="important" aria-label="Required">*</em>
</label>
<div class="subFrmFieldsHidden subFrmFieldsHiddenCont" style="display:none" elemname="fieldHiddenDiv"><em><svg class="icon icon-Denied-1-01">
<use xlink:href="#icon-rules-denied-01"></use>
</svg></em>
<span>N/A</span>
</div>
<div class="tempContDiv" elemname="fieldContentDiv">
<div class="overflow customCheckBox" role="group" aria-labelledby="Checkbox4-arialabel">
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" aria-describedby="Checkbox4-arialabel hint-Checkbox4" aria-label="No Military Service" type="checkbox" id="Checkbox4_1" class="checkBoxType"
name="Checkbox4" elname="Checkbox4" value="No Military Service" textassign_val="" emailassign_val="" formula_val="" onchange="ZFLive.checkMaxChoiceLimit(this);">
<label for="Checkbox4_1" aria-hidden="true" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">No Military Service</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" aria-describedby="Checkbox4-arialabel hint-Checkbox4" aria-label="Spouse of Military Member" type="checkbox" id="Checkbox4_2" class="checkBoxType"
name="Checkbox4" elname="Checkbox4" value="Spouse of Military Member" textassign_val="" emailassign_val="" formula_val="" onchange="ZFLive.checkMaxChoiceLimit(this);">
<label for="Checkbox4_2" aria-hidden="true" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">Spouse of Military Member</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" aria-describedby="Checkbox4-arialabel hint-Checkbox4" aria-label="Veteran" type="checkbox" id="Checkbox4_3" class="checkBoxType" name="Checkbox4"
elname="Checkbox4" value="Veteran" textassign_val="" emailassign_val="" formula_val="" onchange="ZFLive.checkMaxChoiceLimit(this);">
<label for="Checkbox4_3" aria-hidden="true" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">Veteran</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" aria-describedby="Checkbox4-arialabel hint-Checkbox4" aria-label="Service-Disabled Veteran" type="checkbox" id="Checkbox4_4" class="checkBoxType"
name="Checkbox4" elname="Checkbox4" value="Service-Disabled Veteran" textassign_val="" emailassign_val="" formula_val="" onchange="ZFLive.checkMaxChoiceLimit(this);">
<label for="Checkbox4_4" aria-hidden="true" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">Service-Disabled Veteran</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" aria-describedby="Checkbox4-arialabel hint-Checkbox4" aria-label="Member of the Reserve" type="checkbox" id="Checkbox4_5" class="checkBoxType"
name="Checkbox4" elname="Checkbox4" value="Member of the Reserve" textassign_val="" emailassign_val="" formula_val="" onchange="ZFLive.checkMaxChoiceLimit(this);">
<label for="Checkbox4_5" aria-hidden="true" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">Member of the Reserve</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" aria-describedby="Checkbox4-arialabel hint-Checkbox4" aria-label="Active Duty" type="checkbox" id="Checkbox4_6" class="checkBoxType" name="Checkbox4"
elname="Checkbox4" value="Active Duty" textassign_val="" emailassign_val="" formula_val="" onchange="ZFLive.checkMaxChoiceLimit(this);">
<label for="Checkbox4_6" aria-hidden="true" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">Active Duty</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" aria-describedby="Checkbox4-arialabel hint-Checkbox4" aria-label="National Guard" type="checkbox" id="Checkbox4_7" class="checkBoxType"
name="Checkbox4" elname="Checkbox4" value="National Guard" textassign_val="" emailassign_val="" formula_val="" onchange="ZFLive.checkMaxChoiceLimit(this);">
<label for="Checkbox4_7" aria-hidden="true" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">National Guard</em>
</label> </span>
<div class="clearBoth"></div>
</div>
<p class="errorMessage" elname="error" id="error-Checkbox4"></p>
</div>
<div class="clearBoth"></div>
</li>
<li elname="livefield-elem" comptype="1" id="SingleLine-li" needdata="true" compname="SingleLine" linkname="SingleLine" counteruid="" isvisible="true" isunique="false" class="tempFrmWrapper small" mandatory="true" page_no="1"
page_link_name="Page" showlabel="true">
<label class="labelName" for="SingleLine-arialabel">
<span>Business Name</span>
<em class="important" aria-label="Required">*</em>
</label>
<div class="subFrmFieldsHidden subFrmFieldsHiddenCont" style="display:none" elemname="fieldHiddenDiv"><em><svg class="icon icon-Denied-1-01">
<use xlink:href="#icon-rules-denied-01"></use>
</svg></em>
<span>N/A</span>
</div>
<div class="tempContDiv" elemname="fieldContentDiv" incwebhk_name="fieldContentDiv">
<span> <b class="inptCont"> <input id="SingleLine-arialabel" aria-describedby="hint-SingleLine" onkeyup="ZFLive.configureInputMask(this);" onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="off" type="text" maxlength="255" name="SingleLine" value="" placeholder="">
</b> </span>
<p class="errorMessage" elname="error" id="error-SingleLine"></p>
</div>
<div class="clearBoth"></div>
</li>
<li class="zfcheckbox tempFrmWrapper oneColumns " minchoices="1" elname="livefield-elem" comptype="14" needdata="true" id="Checkbox5-li" compname="Checkbox5" linkname="Checkbox5" isvisible="true" mandatory="true" page_no="1"
page_link_name="Page" choice_type="checkbox" counteruid="">
<label id="Checkbox5-arialabel" class="labelName"><span>Currently in Business?</span>
<em class="important" aria-label="Required">*</em>
</label>
<div class="subFrmFieldsHidden subFrmFieldsHiddenCont" style="display:none" elemname="fieldHiddenDiv"><em><svg class="icon icon-Denied-1-01">
<use xlink:href="#icon-rules-denied-01"></use>
</svg></em>
<span>N/A</span>
</div>
<div class="tempContDiv" elemname="fieldContentDiv">
<div class="overflow customCheckBox" role="group" aria-labelledby="Checkbox5-arialabel">
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" aria-describedby="Checkbox5-arialabel hint-Checkbox5" aria-label="Yes" type="checkbox" id="Checkbox5_1" class="checkBoxType" name="Checkbox5"
elname="Checkbox5" value="Yes" textassign_val="" emailassign_val="" formula_val="" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);">
<label for="Checkbox5_1" aria-hidden="true" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">Yes</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" aria-describedby="Checkbox5-arialabel hint-Checkbox5" aria-label="No" type="checkbox" id="Checkbox5_2" class="checkBoxType" name="Checkbox5"
elname="Checkbox5" value="No" textassign_val="" emailassign_val="" formula_val="" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);">
<label for="Checkbox5_2" aria-hidden="true" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">No</em>
</label> </span>
<div class="clearBoth"></div>
</div>
<p class="errorMessage" elname="error" id="error-Checkbox5"></p>
</div>
<div class="clearBoth"></div>
</li>
<li class="tempFrmWrapper dropdown small zfSelect2CustomCont" elname="livefield-elem" comptype="12" id="Dropdown-li" needdata="true" compname="Dropdown" linkname="Dropdown" isvisible="true" mandatory="true" page_no="1" page_link_name="Page"
showlabel="true" counteruid="">
<label for="Dropdown-arialabel" id="Dropdown-arialabel-cont" class="labelName">
<span>Type of Business</span>
<em class="important" aria-label="Required">*</em>
</label>
<div class="subFrmFieldsHidden subFrmFieldsHiddenCont" style="display:none" elemname="fieldHiddenDiv"><em><svg class="icon icon-Denied-1-01">
<use xlink:href="#icon-rules-denied-01"></use>
</svg></em>
<span>N/A</span>
</div>
<div class="tempContDiv" elemname="fieldContentDiv" incwebhk_name="fieldContentDiv">
<div class="form_selectBox">
<div class="selectArrow"></div><select id="Dropdown-arialabel" aria-describedby="hint-Dropdown" name="Dropdown" onchange="ZFLive.prefillFieldLabel(this); ZFLive.hideClosestFieldElemErrorDiv(this); ZFLive.checkUniqueChoiceFld(this);
" tabindex="-1" class="select2-hidden-accessible" aria-hidden="true">
<option selected="true" value="-Select-">-Select-</option>
<option value="Accommodation & Food Service" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003291">Accommodation & Food Service</option>
<option value="Administrative & Support" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003293">Administrative & Support</option>
<option value="Agricultural, Forestry, Fishing & Hunting" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003295">Agricultural, Forestry, Fishing & Hunting</option>
<option value="Arts, Entertainment & Recreation" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003297">Arts, Entertainment & Recreation</option>
<option value="Construction" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003299">Construction</option>
<option value="Educational Services" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003301">Educational Services</option>
<option value="Finance & Insurance" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003303">Finance & Insurance</option>
<option value="Health Care & Social Assistance" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003305">Health Care & Social Assistance</option>
<option value="Information" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003281">Information</option>
<option value="Management of Companies" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003307">Management of Companies</option>
<option value="Manufacturing" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003309">Manufacturing</option>
<option value="Mining" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003277">Mining</option>
<option value="Other Services" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003311">Other Services</option>
<option value="Professional, Scientific & Technical" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003313">Professional, Scientific & Technical</option>
<option value="Public Administration" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003315">Public Administration</option>
<option value="Real Estate & Rental & Leasing" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003317">Real Estate & Rental & Leasing</option>
<option value="Retail Trade" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003319">Retail Trade</option>
<option value="Transportation & Warehousing" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003321">Transportation & Warehousing</option>
<option value="Utilities" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003279">Utilities</option>
<option value="Waste Management" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003323">Waste Management</option>
<option value="Wholesale Trade" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003325">Wholesale Trade</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" style="width: 238.5px;"><span class="selection"><span class="select2-selection select2-selection--single select2FormCont" role="combobox"
aria-haspopup="true" aria-expanded="false" tabindex="0" aria-labelledby="select2-Dropdown-arialabel-container"><span class="select2-selection__rendered" id="select2-Dropdown-arialabel-container" title="-Select-">
<div class="select2FormFont drpDwnPlaceholder">-Select-</div>
</span><span class="select2-selection__arrow select2FormArrow" role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
</div>
<div elname="liveFieldTempChoiceCont" style="display: none;">
</div>
<p class="errorMessage" elname="error" id="error-Dropdown"></p>
<p class="instruction instrSpace" elname="hint" id="hint-Dropdown"> (Choose one)</p>
</div>
<div class="clearBoth"></div>
</li>
<li class="tempFrmWrapper dropdown small zfSelect2CustomCont" elname="livefield-elem" comptype="12" id="Dropdown1-li" needdata="true" compname="Dropdown1" linkname="Dropdown1" isvisible="true" mandatory="true" page_no="1"
page_link_name="Page" showlabel="true" counteruid="">
<label for="Dropdown1-arialabel" id="Dropdown1-arialabel-cont" class="labelName">
<span>Referred by?</span>
<em class="important" aria-label="Required">*</em>
</label>
<div class="subFrmFieldsHidden subFrmFieldsHiddenCont" style="display:none" elemname="fieldHiddenDiv"><em><svg class="icon icon-Denied-1-01">
<use xlink:href="#icon-rules-denied-01"></use>
</svg></em>
<span>N/A</span>
</div>
<div class="tempContDiv" elemname="fieldContentDiv" incwebhk_name="fieldContentDiv">
<div class="form_selectBox">
<div class="selectArrow"></div><select id="Dropdown1-arialabel" aria-describedby="hint-Dropdown1" name="Dropdown1" onchange="ZFLive.prefillFieldLabel(this); ZFLive.hideClosestFieldElemErrorDiv(this); ZFLive.checkUniqueChoiceFld(this);
" tabindex="-1" class="select2-hidden-accessible" aria-hidden="true">
<option selected="true" value="-Select-">-Select-</option>
<option value="Boots to Business" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003349">Boots to Business</option>
<option value="Business Owner" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003351">Business Owner</option>
<option value="Chamber of Commerce" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003353">Chamber of Commerce</option>
<option value="Educational Institution" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003355">Educational Institution</option>
<option value="Internet" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003357">Internet</option>
<option value="Lender" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003337">Lender</option>
<option value="Local Economic Development Official" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003359">Local Economic Development Official</option>
<option value="Magazine/Newspaper" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003361">Magazine/Newspaper</option>
<option value="Other Client" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003363">Other Client</option>
<option value="SBA District Office" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003365">SBA District Office</option>
<option value="SBA Web Site" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003367">SBA Web Site</option>
<option value="SBDC" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003335">SBDC</option>
<option value="SCORE" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003369">SCORE</option>
<option value="Television/Radio" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003371">Television/Radio</option>
<option value="USEAC" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003339">USEAC</option>
<option value="VBOC" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003373">VBOC</option>
<option value="Women's Business Center" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003375">Women's Business Center</option>
<option value="Word of Mouth" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003377">Word of Mouth</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" style="width: 238.5px;"><span class="selection"><span class="select2-selection select2-selection--single select2FormCont" role="combobox"
aria-haspopup="true" aria-expanded="false" tabindex="0" aria-labelledby="select2-Dropdown1-arialabel-container"><span class="select2-selection__rendered" id="select2-Dropdown1-arialabel-container" title="-Select-">
<div class="select2FormFont drpDwnPlaceholder">-Select-</div>
</span><span class="select2-selection__arrow select2FormArrow" role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
</div>
<div elname="liveFieldTempChoiceCont" style="display: none;">
</div>
<p class="errorMessage" elname="error" id="error-Dropdown1"></p>
<p class="instruction instrSpace" elname="hint" id="hint-Dropdown1"> (Choose One)</p>
</div>
<div class="clearBoth"></div>
</li>
<li class="tempFrmWrapper dropdown small zfSelect2CustomCont" elname="livefield-elem" comptype="12" id="Dropdown2-li" needdata="true" compname="Dropdown2" linkname="Dropdown2" isvisible="true" mandatory="true" page_no="1"
page_link_name="Page" showlabel="true" counteruid="">
<label for="Dropdown2-arialabel" id="Dropdown2-arialabel-cont" class="labelName">
<span>What is the nature of the counseling you are seeking?</span>
<em class="important" aria-label="Required">*</em>
</label>
<div class="subFrmFieldsHidden subFrmFieldsHiddenCont" style="display:none" elemname="fieldHiddenDiv"><em><svg class="icon icon-Denied-1-01">
<use xlink:href="#icon-rules-denied-01"></use>
</svg></em>
<span>N/A</span>
</div>
<div class="tempContDiv" elemname="fieldContentDiv" incwebhk_name="fieldContentDiv">
<div class="form_selectBox">
<div class="selectArrow"></div><select id="Dropdown2-arialabel" aria-describedby="hint-Dropdown2" name="Dropdown2" onchange="ZFLive.prefillFieldLabel(this); ZFLive.hideClosestFieldElemErrorDiv(this); ZFLive.checkUniqueChoiceFld(this);
" tabindex="-1" class="select2-hidden-accessible" aria-hidden="true">
<option selected="true" value="-Select-">-Select-</option>
<option value="Business Accounting/Budget" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003401">Business Accounting/Budget</option>
<option value="Business Plan" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003389">Business Plan</option>
<option value="Buy/Sell Business" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003403">Buy/Sell Business</option>
<option value="Cash Flow Management" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003405">Cash Flow Management</option>
<option value="Customer Relations" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003407">Customer Relations</option>
<option value="Financing/Capital (Such as applying for a loan or building equity capital)" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003391">Financing/Capital (Such as applying for a loan or building
equity capital)</option>
<option value="Franchising" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003409">Franchising</option>
<option value="Government Contracting (including certifications)" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003411">Government Contracting (including certifications)</option>
<option value="Human Resources/Managing Employees" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003413">Human Resources/Managing Employees</option>
<option value="International Trade" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003415">International Trade</option>
<option value="Legal Issues (such as Should I Incorporate?)" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003417">Legal Issues (such as Should I Incorporate?)</option>
<option value="Managing a Business" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003419">Managing a Business</option>
<option value="Marketing/Sales (promotion, market research, pricing, etc)" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003421">Marketing/Sales (promotion, market research, pricing, etc)</option>
<option value="Startup Assistance (How do I start a small business?)" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003387">Startup Assistance (How do I start a small business?)</option>
<option value="Tax Planning" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003423">Tax Planning</option>
<option value="Technology/Computers" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003425">Technology/Computers</option>
<option value="eCommerce" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003427">eCommerce</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" style="width: 238.5px;"><span class="selection"><span class="select2-selection select2-selection--single select2FormCont" role="combobox"
aria-haspopup="true" aria-expanded="false" tabindex="0" aria-labelledby="select2-Dropdown2-arialabel-container"><span class="select2-selection__rendered" id="select2-Dropdown2-arialabel-container" title="-Select-">
<div class="select2FormFont drpDwnPlaceholder">-Select-</div>
</span><span class="select2-selection__arrow select2FormArrow" role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
</div>
<div elname="liveFieldTempChoiceCont" style="display: none;">
</div>
<p class="errorMessage" elname="error" id="error-Dropdown2"></p>
</div>
<div class="clearBoth"></div>
</li>
<li tabindex="1" isunique="false" class="tempFrmWrapper date" elname="livefield-elem" comptype="5" id="Date-li" compname="Date" linkname="Date" needdata="true" isvisible="true" disableddays="{}" startoftheweek="0" mandatory="false"
page_no="1" page_link_name="Page" showlabel="true" counteruid="">
<label class="labelName" for="Date-date">
<span>Date Business Started</span>
</label>
<div class="subFrmFieldsHidden subFrmFieldsHiddenCont" style="display:none" elemname="fieldHiddenDiv"><em><svg class="icon icon-Denied-1-01">
<use xlink:href="#icon-rules-denied-01"></use>
</svg></em>
<span>N/A</span>
</div>
<div class="tempContDiv" datelocale="en-GB" elname="dd-M-yy" id="DatedateDiv" isdisable="false" elemname="fieldContentDiv">
<span>
<div class="calendarCont" elname="calendarContDiv">
<input aria-describedby="hint-Date Date-subInfoText" aria-haspopup="dialog" name="Date" elname="date" id="Date-date" onchange="ZFLive.validateFieldConstraint(this);" onfocusout="checkDatePicker(this);" autocomplete="off"
onclick="ZFUtil.showLiveDatePicker(this)" onfocus="ZFUtil.showLiveDatePicker(this)" type="text" value="" placeholder="" class="hasDatepicker">
<div class="calIconWrapper" role="img" aria-label="Date" elname="imgWrapDiv"><img class="calendarIcon" src="https://static.zohocdn.com/forms/images/spacer.325472601571f31e1bf00674c368d335.gif" title="..."></div>
<div class="clearBoth"></div>
</div>
<label class="formSubInfoText" elname="formSubInfoText" id="Date-subInfoText">dd-MMM-yyyy</label>
</span>
<p class="errorMessage" elname="error" id="error-Date"></p>
<p class="instruction instrLeftSpace" elname="hint" id="hint-Date"> (Only Existing Business)</p>
<span style="display:none">
<script type="module">
$(function() {
var dateformat = $("#DatedateDiv").attr("elname"); // No I18N
var actualDateFormat = "dd-MMM-yyyy"; // No I18N
var dateLocale = $("#DatedateDiv").attr("datelocale"); // No I18N
var weekStart = "0"; // No I18N
if (typeof weekStart == ResponseKey.UNDEFINED || weekStart == "") {
weekStart = 0;
}
if (typeof dateLocale == ResponseKey.UNDEFINED || dateLocale == "") {
dateLocale = "en-GB"; // No I18N
}
var disableDays = {};
$("#Date-date").datepicker({
showOn: "button", // No I18N
buttonImage: "https://static.zohocdn.com/forms/images/spacer.325472601571f31e1bf00674c368d335.gif", // No I18N
buttonImageOnly: true,
dateFormat: dateformat,
showAnim: "drop", // No I18N
changeMonth: true,
yearRange: "1900:2100",
firstDay: weekStart,
beforeShowDay: function(date) {
return ZFUtil.blockDisabledDaysAndHolidays(date, disableDays);
},
beforeShow: function() {
ZFUtil.setDateLimit(this, actualDateFormat, dateLocale);
},
onClose: function() {},
onChangeMonthYear: function(year, month, inst) {},
monthNamesShort: CustomDateLocale[dateLocale].monthNamesShort,
monthNames: CustomDateLocale[dateLocale].monthNames,
dayNamesMin: CustomDateLocale[dateLocale].dayNamesMin,
showMonthAfterYear: CustomDateLocale[dateLocale].showMonthAfterYear,
yearSuffix: CustomDateLocale[dateLocale].yearSuffix,
changeYear: true
});
var dateDiv = $("#DatedateDiv"); // No I18N
var imgElem = $(dateDiv).find('img'); // No I18N
$(imgElem).removeClass("ui-datepicker-trigger"); // No I18N
$(imgElem).addClass("calendarIcon"); // No I18N
$(imgElem).mousedown(function(e) {
e.preventDefault();
});
//$(imgElem).attr("title",""); // Hovering on date picker icon displays the Date field's label
$(imgElem).removeAttr("alt"); // No I18N
/*
When spacing is applied for input fields in Themes, calendar icon needs to vertical aligned with input.
For that img element should be placed inside a div.
*/
var imgWrapDiv = $('<div class="calIconWrapper" role="img" aria-label="Date" elname="imgWrapDiv"></div>');
$(imgWrapDiv).insertBefore(imgElem);
$(imgElem).appendTo(imgWrapDiv);
//The below class add to set z-index
$('#ui-datepicker-div').addClass("calIndex");
$('#ui-datepicker-div').addClass("notranslate");
if (false == true) {
$("#Date-date").datepicker().datepicker('disable'); //No I18N
}
});
//$("#DatedateDiv").find('img').addClass("calendarIcon");
</script>
</span>
</div>
</li>
<li tabindex="1" class="slider tempFrmWrapper small" elname="livefield-elem" comptype="23" id="Slider-li" needdata="true" compname="Slider" linkname="Slider" isvisible="true" isdisable="false" mandatory="false" page_no="1"
page_link_name="Page" slidertype="1" slidermin="0" slidermax="100" summary_type="0" step_value="1" show_stepby_value="" show_stepby_point="" counteruid="">
<label id="Slider-arialabel" class="labelName"><span>Business Ownership Male</span>
</label>
<div class="subFrmFieldsHidden subFrmFieldsHiddenCont" style="display:none" elemname="fieldHiddenDiv"><em><svg class="icon icon-Denied-1-01">
<use xlink:href="#icon-rules-denied-01"></use>
</svg></em>
<span>N/A</span>
</div>
<div class="tempContDiv" elname="sliderFormatElem" sliderformat="" elemname="fieldContentDiv">
<div class="sliderCont">
<script type="module">
$(function() {
var isRtlEnabled = false; // No I18N
var txtDir = "1"; // No I18N
var rangeDirection = "min"; // No I18N
if (txtDir != null && txtDir != undefined) { // No I18N
if (txtDir == 2) { // No I18N
isRtlEnabled = true; // No I18N
rangeDirection = "max"; // No I18N
}
}
var inite = "";
if (inite === undefined || inite < 0 || inite > 100 || ((Number(inite) - Number(0)) % 1) != 0) { // No I18N
inite = "";
}
var circularSlider = $("#slid-Slider").closest("a[elname=circular-slider]"); // No I18N
if (inite != "") {
$("#slid_Slider_Div").show(); // No I18N
$(circularSlider).attr("aria-valuenow", inite); // No I18N
} else {
$("#slid_Slider_Div").hide(); // No I18N
$(circularSlider).attr("aria-valuenow", 0); // No I18N
}
$("#slid-Slider").text(inite); // No I18N
var compname = "Slider"; // No I18N
var stopTriggered = false; // No I18N
var downEventTriggered = false; // No I18N
var moveEventTriggered = false; // No I18N
$("#sld-Slider").slider({
orientation: "1", // No I18N
range: rangeDirection, // No I18N
min: 0,
max: 100,
animate: "300", // No I18N
value: inite,
step: 1, // No I18N
isRTL: isRtlEnabled, // No I18N
slide: function(event, ui) {
if (event.originalEvent != undefined) { // No I18N
if (event.originalEvent.type === "mousedown") {
downEventTriggered = true; // No I18N
} else if (event.originalEvent.type === "mousemove") { // No I18N
moveEventTriggered = true; // No I18N
}
if (!stopTriggered && (downEventTriggered && moveEventTriggered)) { // No I18N
return false; // No I18N
}
}
var slidval = ui.value;
$("#amount-Slider").attr("value", slidval); // No I18N
$("#slid-Slider").text(slidval); // No I18N
$("#slid_Slider_Div").show();
stopTriggered = false; // No I18N
},
stop: function(event, ui) { // No I18N
stopTriggered = true; // No I18N
downEventTriggered = false; // No I18N
moveEventTriggered = false; // No I18N
setSfTotalValForSlider("Slider"); // No I18N
var liElem = getFieldElem(compname);
ZFLive.prefillFieldLabelFromLiElem(liElem, false);
removeErrorFromLiElemForSlider(compname); // No I18N
}
});
if (false == true) {
$("#sld-Slider").slider({
disabled: true
});
}
var showPoint = ""; // No I18N
var showValue = ""; // No I18N
if (showPoint == "true") {
showPoint = true; // No I18N
} else { // No I18N
showPoint = false; // No I18N
}
if (showValue == "true") {
showValue = true; // No I18N
} else { // No I18N
showValue = false; // No I18N
}
ZFLive.setSliderIndicators("#sld-Slider", 1, 0, 100, showPoint, showValue, isRtlEnabled, inite); // No I18N
$("#amount-Slider").attr("value", inite); // No I18N
});
</script>
<div id="amount-Slider" name="slider" value=""></div>
<div id="sld-Slider" class="ui-slider ui-slider-horizontal ui-widget ui-widget-content ui-corner-all"><a aria-labelledby="Slider-arialabel" role="slider" aria-valuemin="0" aria-valuemax="100" elname="circular-slider" aria-describedby="hint-Slider" class="ui-slider-handle ui-state-default ui-corner-all" style="left: 0%;" aria-valuenow="0">
<div id="slid_Slider_Div" class="slideActCont" style="display: none;"><div id="slid-Slider"></div>
<img class="slideArrow" aria-hidden="true"></div></a>
<div class="ui-slider-range ui-widget-header ui-corner-all ui-slider-range-min" style="width: 0%;"></div>
</div>
<div class="sliderValueCont">
<div class="flLeft sliderValue" aria-hidden="true">| <em>0 </em></div>
<div class="flRight sliderValue rt" aria-hidden="true">| <em>100 </em></div>
<div class="clearBoth"></div>
</div>
</div>
<div class="clearBoth"></div>
<p class="errorMessage" elname="error" id="error-Slider"></p>
<p class="instruction" elname="hint" id="hint-Slider"> (Slide for Total Amount of Male Ownership)</p>
</div>
<div class="clearBoth"></div>
</li>
<li tabindex="1" class="slider tempFrmWrapper small" elname="livefield-elem" comptype="23" id="Slider1-li" needdata="true" compname="Slider1" linkname="Slider1" isvisible="true" isdisable="false" mandatory="false" page_no="1"
page_link_name="Page" slidertype="1" slidermin="0" slidermax="100" summary_type="0" step_value="1" show_stepby_value="" show_stepby_point="" counteruid="">
<label id="Slider1-arialabel" class="labelName"><span>Business Ownership Female</span>
</label>
<div class="subFrmFieldsHidden subFrmFieldsHiddenCont" style="display:none" elemname="fieldHiddenDiv"><em><svg class="icon icon-Denied-1-01">
<use xlink:href="#icon-rules-denied-01"></use>
</svg></em>
<span>N/A</span>
</div>
<div class="tempContDiv" elname="sliderFormatElem" sliderformat="" elemname="fieldContentDiv">
<div class="sliderCont">
<script type="module">
$(function() {
var isRtlEnabled = false; // No I18N
var txtDir = "1"; // No I18N
var rangeDirection = "min"; // No I18N
if (txtDir != null && txtDir != undefined) { // No I18N
if (txtDir == 2) { // No I18N
isRtlEnabled = true; // No I18N
rangeDirection = "max"; // No I18N
}
}
var inite = "";
if (inite === undefined || inite < 0 || inite > 100 || ((Number(inite) - Number(0)) % 1) != 0) { // No I18N
inite = "";
}
var circularSlider = $("#slid-Slider1").closest("a[elname=circular-slider]"); // No I18N
if (inite != "") {
$("#slid_Slider1_Div").show(); // No I18N
$(circularSlider).attr("aria-valuenow", inite); // No I18N
} else {
$("#slid_Slider1_Div").hide(); // No I18N
$(circularSlider).attr("aria-valuenow", 0); // No I18N
}
$("#slid-Slider1").text(inite); // No I18N
var compname = "Slider1"; // No I18N
var stopTriggered = false; // No I18N
var downEventTriggered = false; // No I18N
var moveEventTriggered = false; // No I18N
$("#sld-Slider1").slider({
orientation: "1", // No I18N
range: rangeDirection, // No I18N
min: 0,
max: 100,
animate: "300", // No I18N
value: inite,
step: 1, // No I18N
isRTL: isRtlEnabled, // No I18N
slide: function(event, ui) {
if (event.originalEvent != undefined) { // No I18N
if (event.originalEvent.type === "mousedown") {
downEventTriggered = true; // No I18N
} else if (event.originalEvent.type === "mousemove") { // No I18N
moveEventTriggered = true; // No I18N
}
if (!stopTriggered && (downEventTriggered && moveEventTriggered)) { // No I18N
return false; // No I18N
}
}
var slidval = ui.value;
$("#amount-Slider1").attr("value", slidval); // No I18N
$("#slid-Slider1").text(slidval); // No I18N
$("#slid_Slider1_Div").show();
stopTriggered = false; // No I18N
},
stop: function(event, ui) { // No I18N
stopTriggered = true; // No I18N
downEventTriggered = false; // No I18N
moveEventTriggered = false; // No I18N
setSfTotalValForSlider("Slider1"); // No I18N
var liElem = getFieldElem(compname);
ZFLive.prefillFieldLabelFromLiElem(liElem, false);
removeErrorFromLiElemForSlider(compname); // No I18N
}
});
if (false == true) {
$("#sld-Slider1").slider({
disabled: true
});
}
var showPoint = ""; // No I18N
var showValue = ""; // No I18N
if (showPoint == "true") {
showPoint = true; // No I18N
} else { // No I18N
showPoint = false; // No I18N
}
if (showValue == "true") {
showValue = true; // No I18N
} else { // No I18N
showValue = false; // No I18N
}
ZFLive.setSliderIndicators("#sld-Slider1", 1, 0, 100, showPoint, showValue, isRtlEnabled, inite); // No I18N
$("#amount-Slider1").attr("value", inite); // No I18N
});
</script>
<div id="amount-Slider1" name="slider" value=""></div>
<div id="sld-Slider1" class="ui-slider ui-slider-horizontal ui-widget ui-widget-content ui-corner-all"><a aria-labelledby="Slider1-arialabel" role="slider" aria-valuemin="0" aria-valuemax="100" elname="circular-slider" aria-describedby="hint-Slider1" class="ui-slider-handle ui-state-default ui-corner-all" style="left: 0%;" aria-valuenow="0">
<div id="slid_Slider1_Div" class="slideActCont" style="display: none;"><div id="slid-Slider1"></div>
<img class="slideArrow" aria-hidden="true"></div></a>
<div class="ui-slider-range ui-widget-header ui-corner-all ui-slider-range-min" style="width: 0%;"></div>
</div>
<div class="sliderValueCont">
<div class="flLeft sliderValue" aria-hidden="true">| <em>0 </em></div>
<div class="flRight sliderValue rt" aria-hidden="true">| <em>100 </em></div>
<div class="clearBoth"></div>
</div>
</div>
<div class="clearBoth"></div>
<p class="errorMessage" elname="error" id="error-Slider1"></p>
<p class="instruction" elname="hint" id="hint-Slider1"> (Slide for Total Amount of Female Ownership)</p>
</div>
<div class="clearBoth"></div>
</li>
<li class="zfcheckbox tempFrmWrapper oneColumns " elname="livefield-elem" comptype="14" needdata="true" id="Checkbox6-li" compname="Checkbox6" linkname="Checkbox6" isvisible="true" mandatory="false" page_no="1" page_link_name="Page"
choice_type="checkbox" counteruid="">
<label id="Checkbox6-arialabel" class="labelName"><span>Do you conduct business online?</span>
</label>
<div class="subFrmFieldsHidden subFrmFieldsHiddenCont" style="display:none" elemname="fieldHiddenDiv"><em><svg class="icon icon-Denied-1-01">
<use xlink:href="#icon-rules-denied-01"></use>
</svg></em>
<span>N/A</span>
</div>
<div class="tempContDiv" elemname="fieldContentDiv">
<div class="overflow customCheckBox" role="group" aria-labelledby="Checkbox6-arialabel">
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" aria-describedby="Checkbox6-arialabel hint-Checkbox6" aria-label="Yes" type="checkbox" id="Checkbox6_1" class="checkBoxType" name="Checkbox6"
elname="Checkbox6" value="Yes" textassign_val="" emailassign_val="" formula_val="" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);">
<label for="Checkbox6_1" aria-hidden="true" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">Yes</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" aria-describedby="Checkbox6-arialabel hint-Checkbox6" aria-label="No" type="checkbox" id="Checkbox6_2" class="checkBoxType" name="Checkbox6"
elname="Checkbox6" value="No" textassign_val="" emailassign_val="" formula_val="" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);">
<label for="Checkbox6_2" aria-hidden="true" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">No</em>
</label> </span>
<div class="clearBoth"></div>
</div>
<p class="errorMessage" elname="error" id="error-Checkbox6"></p>
</div>
<div class="clearBoth"></div>
</li>
<li class="zfcheckbox tempFrmWrapper oneColumns " elname="livefield-elem" comptype="14" needdata="true" id="Checkbox7-li" compname="Checkbox7" linkname="Checkbox7" isvisible="true" mandatory="false" page_no="1" page_link_name="Page"
choice_type="checkbox" counteruid="">
<label id="Checkbox7-arialabel" class="labelName"><span>Are you a Home Based Business?</span>
</label>
<div class="subFrmFieldsHidden subFrmFieldsHiddenCont" style="display:none" elemname="fieldHiddenDiv"><em><svg class="icon icon-Denied-1-01">
<use xlink:href="#icon-rules-denied-01"></use>
</svg></em>
<span>N/A</span>
</div>
<div class="tempContDiv" elemname="fieldContentDiv">
<div class="overflow customCheckBox" role="group" aria-labelledby="Checkbox7-arialabel">
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" aria-describedby="Checkbox7-arialabel hint-Checkbox7" aria-label="Yes" type="checkbox" id="Checkbox7_1" class="checkBoxType" name="Checkbox7"
elname="Checkbox7" value="Yes" textassign_val="" emailassign_val="" formula_val="" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);">
<label for="Checkbox7_1" aria-hidden="true" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">Yes</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" aria-describedby="Checkbox7-arialabel hint-Checkbox7" aria-label="No" type="checkbox" id="Checkbox7_2" class="checkBoxType" name="Checkbox7"
elname="Checkbox7" value="No" textassign_val="" emailassign_val="" formula_val="" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);">
<label for="Checkbox7_2" aria-hidden="true" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">No</em>
</label> </span>
<div class="clearBoth"></div>
</div>
<p class="errorMessage" elname="error" id="error-Checkbox7"></p>
</div>
<div class="clearBoth"></div>
</li>
<li class="zfcheckbox tempFrmWrapper oneColumns " elname="livefield-elem" comptype="14" needdata="true" id="Checkbox8-li" compname="Checkbox8" linkname="Checkbox8" isvisible="true" mandatory="false" page_no="1" page_link_name="Page"
choice_type="checkbox" counteruid="">
<label id="Checkbox8-arialabel" class="labelName"><span>Are you 8(a) Certified?</span>
</label>
<div class="subFrmFieldsHidden subFrmFieldsHiddenCont" style="display:none" elemname="fieldHiddenDiv"><em><svg class="icon icon-Denied-1-01">
<use xlink:href="#icon-rules-denied-01"></use>
</svg></em>
<span>N/A</span>
</div>
<div class="tempContDiv" elemname="fieldContentDiv">
<div class="overflow customCheckBox" role="group" aria-labelledby="Checkbox8-arialabel">
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" aria-describedby="Checkbox8-arialabel hint-Checkbox8" aria-label="Yes" type="checkbox" id="Checkbox8_1" class="checkBoxType" name="Checkbox8"
elname="Checkbox8" value="Yes" textassign_val="" emailassign_val="" formula_val="" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);">
<label for="Checkbox8_1" aria-hidden="true" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">Yes</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" aria-describedby="Checkbox8-arialabel hint-Checkbox8" aria-label="No" type="checkbox" id="Checkbox8_2" class="checkBoxType" name="Checkbox8"
elname="Checkbox8" value="No" textassign_val="" emailassign_val="" formula_val="" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);">
<label for="Checkbox8_2" aria-hidden="true" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">No</em>
</label> </span>
<div class="clearBoth"></div>
</div>
<p class="errorMessage" elname="error" id="error-Checkbox8"></p>
</div>
<div class="clearBoth"></div>
</li>
<li isunique="false" class="tempFrmWrapper small" elname="livefield-elem" comptype="3" id="Number-li" needdata="true" compname="Number" linkname="Number" isvisible="true" mandatory="false" unit_position="2" page_no="1" page_link_name="Page"
summary_type="0" showlabel="true" counteruid="" need_reconf="false">
<label class="labelName" for="Number-arialabel">
<span>Number of Full-Time Empolyees</span>
<span class="sr-only"></span>
</label>
<div class="subFrmFieldsHidden subFrmFieldsHiddenCont" style="display:none" elemname="fieldHiddenDiv"><em><svg class="icon icon-Denied-1-01">
<use xlink:href="#icon-rules-denied-01"></use>
</svg></em>
<span>N/A</span>
</div>
<div elname="tempContDiv" class="tempContDiv numberContDiv" elemname="fieldContentDiv" incwebhk_name="fieldContentDiv">
<span> <b class="inptCont"> <input id="Number-arialabel" aria-describedby="hint-Number" onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="off" type="text" inputmode="numeric" maxlength="18" name="Number" value="" placeholder="">
</b> </span>
<span class="symbol" name="field_unit_after" elname="field_unit_span" aria-hidden="true"></span>
<p class="errorMessage" elname="error" id="error-Number"></p>
</div>
<div class="clearBoth"></div>
</li>
<li isunique="false" class="tempFrmWrapper small" elname="livefield-elem" comptype="3" id="Number1-li" needdata="true" compname="Number1" linkname="Number1" isvisible="true" mandatory="false" unit_position="2" page_no="1"
page_link_name="Page" summary_type="0" showlabel="true" counteruid="" need_reconf="false">
<label class="labelName" for="Number1-arialabel">
<span>Number of Part-Time Employees</span>
<span class="sr-only"></span>
</label>
<div class="subFrmFieldsHidden subFrmFieldsHiddenCont" style="display:none" elemname="fieldHiddenDiv"><em><svg class="icon icon-Denied-1-01">
<use xlink:href="#icon-rules-denied-01"></use>
</svg></em>
<span>N/A</span>
</div>
<div elname="tempContDiv" class="tempContDiv numberContDiv" elemname="fieldContentDiv" incwebhk_name="fieldContentDiv">
<span> <b class="inptCont"> <input id="Number1-arialabel" aria-describedby="hint-Number1" onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="off" type="text" inputmode="numeric" maxlength="18" name="Number1" value="" placeholder="">
</b> </span>
<span class="symbol" name="field_unit_after" elname="field_unit_span" aria-hidden="true"></span>
<p class="errorMessage" elname="error" id="error-Number1"></p>
</div>
<div class="clearBoth"></div>
</li>
<li class="tempFrmWrapper dropdown small zfSelect2CustomCont" elname="livefield-elem" comptype="12" id="Dropdown3-li" needdata="true" compname="Dropdown3" linkname="Dropdown3" isvisible="true" mandatory="false" page_no="1"
page_link_name="Page" showlabel="true" counteruid="">
<label for="Dropdown3-arialabel" id="Dropdown3-arialabel-cont" class="labelName">
<span>Legal Structure</span>
</label>
<div class="subFrmFieldsHidden subFrmFieldsHiddenCont" style="display:none" elemname="fieldHiddenDiv"><em><svg class="icon icon-Denied-1-01">
<use xlink:href="#icon-rules-denied-01"></use>
</svg></em>
<span>N/A</span>
</div>
<div class="tempContDiv" elemname="fieldContentDiv" incwebhk_name="fieldContentDiv">
<div class="form_selectBox">
<div class="selectArrow"></div><select id="Dropdown3-arialabel" aria-describedby="hint-Dropdown3" name="Dropdown3" onchange="ZFLive.prefillFieldLabel(this); ZFLive.hideClosestFieldElemErrorDiv(this); ZFLive.checkUniqueChoiceFld(this);
" tabindex="-1" class="select2-hidden-accessible" aria-hidden="true">
<option selected="true" value="-Select-">-Select-</option>
<option value="LLC-Limited Liability Company" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003581">LLC-Limited Liability Company</option>
<option value="C-Corporation" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003583">C-Corporation</option>
<option value="S-Corporation" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003585">S-Corporation</option>
<option value="DBA-Doing Business As/Sole Proprietorship" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003595">DBA-Doing Business As/Sole Proprietorship</option>
<option value="Partnership" formula_val="" textassign_val="" emailassign_val="" option_id="1323003000000003597">Partnership</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" style="width: 238.5px;"><span class="selection"><span class="select2-selection select2-selection--single select2FormCont" role="combobox"
aria-haspopup="true" aria-expanded="false" tabindex="0" aria-labelledby="select2-Dropdown3-arialabel-container"><span class="select2-selection__rendered" id="select2-Dropdown3-arialabel-container" title="-Select-">
<div class="select2FormFont drpDwnPlaceholder">-Select-</div>
</span><span class="select2-selection__arrow select2FormArrow" role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
</div>
<div elname="liveFieldTempChoiceCont" style="display: none;">
</div>
<p class="errorMessage" elname="error" id="error-Dropdown3"></p>
</div>
<div class="clearBoth"></div>
</li>
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page_link_name="Page" summary_type="0" showlabel="true" counteruid="" need_reconf="false">
<label class="labelName" for="Number2-arialabel">
<span>For your most recent full business year, what were your:</span>
<span class="sr-only"></span>
</label>
<div class="subFrmFieldsHidden subFrmFieldsHiddenCont" style="display:none" elemname="fieldHiddenDiv"><em><svg class="icon icon-Denied-1-01">
<use xlink:href="#icon-rules-denied-01"></use>
</svg></em>
<span>N/A</span>
</div>
<div elname="tempContDiv" class="tempContDiv numberContDiv" elemname="fieldContentDiv" incwebhk_name="fieldContentDiv">
<span> <b class="inptCont"> <input id="Number2-arialabel" aria-describedby="hint-Number2" onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="off" type="text" inputmode="numeric" maxlength="18" name="Number2" value="" placeholder="">
</b> </span>
<span class="symbol" name="field_unit_after" elname="field_unit_span" aria-hidden="true"></span>
<p class="errorMessage" elname="error" id="error-Number2"></p>
<p class="instruction instrSpace" elname="hint" id="hint-Number2"> Gross Revenue/Sales: ( In Dollars) </p>
</div>
<div class="clearBoth"></div>
</li>
<li isunique="false" class="tempFrmWrapper small" elname="livefield-elem" comptype="3" id="Number3-li" needdata="true" compname="Number3" linkname="Number3" isvisible="true" mandatory="false" unit_position="2" page_no="1"
page_link_name="Page" summary_type="0" showlabel="true" counteruid="" need_reconf="false">
<label class="labelName" for="Number3-arialabel">
<span>For your most recent full business year, what were your:</span>
<span class="sr-only"></span>
</label>
<div class="subFrmFieldsHidden subFrmFieldsHiddenCont" style="display:none" elemname="fieldHiddenDiv"><em><svg class="icon icon-Denied-1-01">
<use xlink:href="#icon-rules-denied-01"></use>
</svg></em>
<span>N/A</span>
</div>
<div elname="tempContDiv" class="tempContDiv numberContDiv" elemname="fieldContentDiv" incwebhk_name="fieldContentDiv">
<span> <b class="inptCont"> <input id="Number3-arialabel" aria-describedby="hint-Number3" onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="off" type="text" inputmode="numeric" maxlength="18" name="Number3" value="" placeholder="">
</b> </span>
<span class="symbol" name="field_unit_after" elname="field_unit_span" aria-hidden="true"></span>
<p class="errorMessage" elname="error" id="error-Number3"></p>
<p class="instruction instrSpace" elname="hint" id="hint-Number3"> + Profits / - Losses: (In Dollars) </p>
</div>
<div class="clearBoth"></div>
</li>
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<li tabindex="1" id="HtmlText-li" class="tempFrmWrapper note" elem_type_int="5" elname="livefield-elem" compname="HtmlText" comptype="0" page_no="1" page_link_name="Page" counteruid="">
<label class="descFld" elname="descFldLabel">
<div title="Page 1" class="page">
<div class="section">
<div class="layoutArea">
<div class="column">
<p><span class="size" style="font-size: 10pt"><span class="size" style="font-size: 24px"><b>Confidentiality Agreement and Signature (ALL clients must sign)</b></span></span><br></p>
<p><span style="font-size: 7pt">I request business counseling service from the Small Business Administration (SBA) or an SBA Resource Partner. I agree to cooperate should I be selected to participate in surveys designed to
evaluate SBA services. I understand any information disclosed will be held in strict confidence. (SBA will not provide your personal information to commercial entities). I authorize SBA to furnish relevent information to the
assigned management counselor(s). I further understand that the counselor(s) agrees not to: 1) recommend goods or services from sources in which they have an interest, and 2) accept fees or commissions developing from this
counseling relationship. In consideration of the counselor(s) furnishing management or technical assistance, I waive all claims against SBA personnel and that of its Resource Partners and host organizations, arising from this
assistance. </span><span style="font-size: 7pt; color: rgb(100%, 0%, 0%)">SBDC services are not available to individuals or entities that have been debarred or suspended by the federal government. By agreeing to receive
assistance from the SBDC with your signature on this form, you are self-certifying that you are not currently federally debarred or suspended and also agree to cease using SBDC services if you become federally debarred or
suspended in the future. </span><span style="font-size: 7pt">Use of Information: </span><span style="font-size: 7pt">The information in this form is to be provided by individuals and businesses seeking technical assistance
services from the Small Business Administration (SBA) or an SBA Resource Partner. The information is collected to help SBA's continuing improvement of business counseling programs, to ensure effective oversight and management
of entrepreneurial development programs and grants, and to meet Congressional and Executive Branch reporting requirements. The form should be submitted at the site of service to the counselor providing the service. Resource
Partners will submit information to SBA according to the terms of their notice of award. </span><span style="font-size: 7pt">I permit SBA or its agent the use of my name and address for SBA surveys and information mailings
regarding SBA products and services ( Yes No ).</span><br></p>
</div>
</div>
</div>
</div>
<div><br></div>
</label>
<div class="clearBoth"></div>
</li>
<li tabindex="1" isunique="false" class="tempFrmWrapper date date-time" elname="livefield-elem" comptype="16" id="DateTime-li" compname="DateTime" linkname="DateTime" needdata="true" isvisible="true" disableddays="{}" startoftheweek="0"
timeslots="" mandatory="false" page_no="1" page_link_name="Page" timeformat="1" showlabel="true" counteruid="">
<label class="labelName" for="DateTime-dateTime">
<span>Date-Time</span>
</label>
<div class="subFrmFieldsHidden subFrmFieldsHiddenCont" style="display:none" elemname="fieldHiddenDiv"><em><svg class="icon icon-Denied-1-01">
<use xlink:href="#icon-rules-denied-01"></use>
</svg></em>
<span>N/A</span>
</div>
<div class="tempContDiv" datelocale="en-GB" elname="dd-M-yy" id="DateTimedateTimeDiv" serverdateformat="dd-MMM-yyyy" isdisable="false" elemname="fieldContentDiv">
<span>
<div class="calendarCont">
<input aria-describedby="hint-DateTime DateTime-subInfoText" aria-haspopup="dialog" name="DateTime" elname="dateTime" id="DateTime-dateTime" onchange="ZFLive.validateFieldConstraint(this);" onfocusout="checkDatePicker(this);"
autocomplete="off" onclick="ZFUtil.datetimepicker('dd-MMM-yyyy','dd-M-yy',this, 'en-GB', true, '1', '0');" onfocus="ZFUtil.datetimepicker('dd-MMM-yyyy','dd-M-yy',this,'en-GB', true, '1', '0');" type="text" value="" placeholder=""
class="hasDatepicker">
<div class="calIconWrapper" role="img" aria-label="Date & Time" elname="imgWrapDiv"><img class="calendarIcon" src="https://static.zohocdn.com/forms/images/spacer.325472601571f31e1bf00674c368d335.gif" title="..."></div>
<div class="clearBoth"></div>
</div>
<label class="formSubInfoText" elname="formSubInfoText" id="DateTime-subInfoText"> dd-MMM-yyyy HH:MM AM/PM </label>
</span>
<p class="errorMessage" elname="error" id="error-DateTime"></p>
<span style="display:none">
<script type="module">
$(function() {
var dateformat = $("#DateTimedateTimeDiv").attr("elname"); // No I18N
var dateLocale = $("#DateTimedateTimeDiv").attr("dateLocale"); // No I18N
ZFUtil.datetimepicker('dd-MMM-yyyy', dateformat, $("#DateTime-dateTime"), dateLocale, false, '1', '0'); // No I18N
var dateTimeDiv = $("#DateTimedateTimeDiv"); // No I18N
var imgElem = $(dateTimeDiv).find('img'); // No I18N
$(imgElem).removeClass("ui-datepicker-trigger"); // No I18N
$(imgElem).addClass("calendarIcon"); // No I18N
$(imgElem).mousedown(function(e) {
e.preventDefault();
});
//$(imgElem).attr("title",""); // Hovering on date picker icon displays the Date field's label
$(imgElem).removeAttr("alt"); // No I18N
/*
When spacing is applied for input fields in Themes, calendar icon needs to vertical aligned with input.
For that img element should be placed inside a div.
*/
var imgWrapDiv = $('<div class="calIconWrapper" role="img" aria-label="Date & Time" elname="imgWrapDiv"></div>');
$(imgWrapDiv).insertBefore(imgElem);
$(imgElem).appendTo($(dateTimeDiv).find("div[elname=imgWrapDiv]"));
//The below class add to set z-index
$('#ui-datepicker-div').addClass("calIndex");
if (false == true) {
$("#DateTime-dateTime").datepicker().datepicker('disable'); //No I18N
}
});
//$("#DateTimedateTimeDiv").find('img').addClass("calendarIcon");
</script>
</span>
</div>
</li>
<li tabindex="1" class="sign tempFrmWrapper large" elname="livefield-elem" comptype="25" id="Signature-li" needdata="true" compname="Signature" linkname="Signature" isvisible="true" mandatory="false" page_no="1" page_link_name="Page"
counteruid="">
<label id="Signature-arialabel" class="labelName"><span>Signature</span>
</label>
<div class="subFrmFieldsHidden subFrmFieldsHiddenCont" style="display:none" elemname="fieldHiddenDiv"><em><svg class="icon icon-Denied-1-01">
<use xlink:href="#icon-rules-denied-01"></use>
</svg></em>
<span>N/A</span>
</div>
<div class="tempContDiv" elemname="fieldContentDiv">
<div class="signContainer" elname="signContainer" id="signContainer-Signature"><span class="sr-only" elname="eSignatureSpan" id="Signature-esign">E-Signature Field</span>
<canvas aria-describedby="hint-Signature" aria-labelledby="Signature-arialabel Signature-esign" aria-disabled="true" tabindex="-1" id="drawingCanvas-Signature" signaturefieldparent="form" width="481"></canvas>
<div class="signArea" elname="signArea" id="sign-area-Signature" style="display:none;height:70px"></div>
<a id="clearSign" role="button" elname="clearSign" class="instrSpace" href="javascript:void(0);" onclick="clearSignature('drawingCanvas-Signature');">Clear</a>
</div>
<p class="errorMessage" elname="error" id="error-Signature"></p>
</div>
<div class="clearBoth"></div>
<script type="module">
setCanvasElemWidth("Signature"); //No I18N
$("#drawingCanvas-Signature").mousedown(function(event) {
var canvasElem = document.getElementById("drawingCanvas-Signature"); //No I18N
var signatureFieldParent = $(canvasElem).attr('signaturefieldparent'); //No I18N
var fontColor = "#000000";
var inputElem = ""; //No I18N
if (signatureFieldParent == "subform") {
inputElem = $("#formBodyDiv").find(".formFieldWrapper li[elemType=subFormField][viewtype=1] input[type=text]:first"); //No I18N
if (inputElem.length == 0) { //No I18N
inputElem = $("#formBodyDiv").find(".formFieldWrapper li[elemType=subFormField][viewtype=1] textarea:first"); //No I18N
}
} else { //No I18N
inputElem = $("#formBodyDiv").find(".formFieldWrapper > .tempFrmWrapper > .tempContDiv input[type=text]:first"); //No I18N
if (inputElem.length == 0) { //No I18N
inputElem = $("#formBodyDiv").find(".formFieldWrapper > .tempFrmWrapper > .tempContDiv textarea:first"); //No I18N
}
}
if (inputElem != "" && inputElem.length > 0) {
fontColor = inputElem.css("color"); // No I18N
}
var context = canvasElem.getContext("2d"); // No I18N
var position = getXYCoords(event, canvasElem, false);
context.moveTo(position.X, position.Y);
context.beginPath();
$(this).mousemove(function(event) {
startScribbling(event, canvasElem, context, false, fontColor);
}).mouseup(function(event) {
endScribbling(event, canvasElem, context, fontColor);
var fieldElem = getClosestFieldElemLi(canvasElem); // No I18N
removeErrorFromLiElem(fieldElem); // No I18N
}).mouseout(function(event) {
endScribbling(event, canvasElem, context, fontColor);
var fieldElem = getClosestFieldElemLi(canvasElem); // No I18N
removeErrorFromLiElem(fieldElem); // No I18N
});
this.addEventListener('touchstart', function(event) {
position = getXYCoords(event, canvasElem, true);
context.moveTo(position.X, position.Y);
context.beginPath();
event.preventDefault();
}, false);
this.addEventListener('touchmove', function(event) {
startScribbling(event, canvasElem, context, true, fontColor);
event.preventDefault();
}, false);
});
var userAgent = window.navigator.userAgent;
var msie = userAgent.indexOf("MSIE ");
if (msie > 0) {
$("#drawingCanvas-Signature").keypress(function(event) {
if (event.keyCode === 13) {
event.preventDefault();
}
});
}
if (false == true) //No I18N
{
$("#drawingCanvas-Signature").css("pointer-events", "none"); //No I18N
$("#drawingCanvas-Signature").css("cursor", "default"); //No I18N
}
</script>
</li>
</ul>
</div>
<ul elname="footer" class="footerWrapper formRelative" page_no="1" page_count="1" counter_page_uid="" page_link_name="Page">
<li style="overflow:visible; position: relative;" class="btnAllign fmFooter" id="formAccess" elname="0">
<div class="pageFotDef">
<div class="alignSubmit">
<div class="formRelative inlineBlock submitBtnCont"><button class="fmSmtButton submitColor submitWrapper fmSmtButtom" elname="submit" value="submit">
<em>Submit</em>
</button></div>
</div>
</div>
<div class="clearBoth"></div>
</li>
</ul>
<!-- Uncomment the following Code to enable automation location based value filling for GeoLocation Fields -->
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<!-- -->
<!--Div to show error for unconfirmed users -->
<div id="errorDiv" style="display:none" class="errorMsgWrapper">
<div class="flLeft errorIcon"></div>
<div class="errorMsgCont" role="alert" aria-live="assertive">
<h2>Error Occurred</h2>
<span id="errorMsgSpan">You haven't verified your email yet, click<a href="javascript:;" onclick="ZFUtil.resendMail('0');"> here </a> to receive a verification email.</span>
</div>
<div class="clearBoth"></div>
</div>
<div class="brandingWrapper">
<div class="brandingTextCont">
<p>
<svg class="icon icon-info" aria-hidden="true">
<use xlink:href="#icon-info"></use>
</svg>
<span>Do not submit confidential information such as credit card details, mobile and ATM PINs, OTPs, account passwords, etc.<a href="https://www.zoho.com/report-abuse/" target="_blank">Report Abuse</a></span>
</p>
</div>
<div class="brandingLogoCont new-Logo"><span class="power-Text">Powered by</span> <a href="https://www.zoho.com/forms?utm_source=freeuser&utm_medium=banner&utm_campaign=formfooter" target="_blank">
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<use xlink:href="#formsLogo-Black"></use>
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<div id="popupdiv" class="dim-div2 dim-div6" style="display:none;">
<div id="imageChoiceDiv-cont" class="popUpOuter imageTypeZoom">
<div class="popUpInnerWrapper">
<div class="popupHeader removeBdr"><a class="flRight ppDeleteIcon" role="button" aria-label="Close" elname="hideZoomedImage" onclick="ZFLive.hideZoomedImage();" href="javascript:;"></a>
<div class="clearBoth"></div>
</div>
<div class="popupMainCont"><img src="" style="display: none;">
<audio aria-label="Recorded media" src="" controls="" style="display: none;"></audio>
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</div>
</form>Text Content
* Jan * Feb * Mar * Apr * May * Jun * Jul * Aug * Sep * Oct * Nov * Dec * SD SBDC REQUEST FOR COUNSELING FORM SBA Form 641 equivalent * Name * N/A Required First Name Required Last Name * Phone * N/A * Email * N/A * Address * N/A Required Street Address Address Line 2 Required City Required State/Region/Province Required Postal / Zip Code Required -Select- Åland Islands Afghanistan Akrotiri Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Ashmore and Cartier Islands Australia Austria Azerbaijan Bahrain Bangladesh Barbados Bassas Da India Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Caribbean Netherlands Cayman Islands Central African Republic Chad Chile China Christmas Island Clipperton Island Cocos (Keeling) Islands Colombia Comoros Cook Islands Coral Sea Islands Costa Rica Cote D'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Democratic Republic of the Congo Denmark Dhekelia Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Europa Island Falkland Islands (Islas Malvinas) Faroe Islands Federated States of Micronesia Fiji Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gaza Strip Georgia Germany Ghana Gibraltar Glorioso Islands Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-bissau Guyana Haiti Heard Island and Mcdonald Islands Holy See (Vatican City) Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Jan Mayen Japan Jersey Jordan Juan De Nova Island Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Navassa Island Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paracel Islands Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Republic of the Congo Reunion Romania Russia Rwanda Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Spratly Islands Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Timor-leste Togo Tokelau Tonga Trinidad and Tobago Tromelin Island Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands Wake Island Wallis and Futuna West Bank Western Sahara Yemen Zambia Zimbabwe United States Country * Race * N/A American Indian or Alaska Native Asian Black/African American Native Hawaiian or Other Pacific Islander White * Ethnicity * N/A Hispanic or Latino Not Hispanic or Latino * Gender * N/A Female Male Other * Do you consider yourself a person with a disability? * N/A Yes No * Military Status * N/A No Military Service Spouse of Military Member Veteran Service-Disabled Veteran Member of the Reserve Active Duty National Guard * Business Name * N/A * Currently in Business? * N/A Yes No * Type of Business * N/A -Select- Accommodation & Food Service Administrative & Support Agricultural, Forestry, Fishing & Hunting Arts, Entertainment & Recreation Construction Educational Services Finance & Insurance Health Care & Social Assistance Information Management of Companies Manufacturing Mining Other Services Professional, Scientific & Technical Public Administration Real Estate & Rental & Leasing Retail Trade Transportation & Warehousing Utilities Waste Management Wholesale Trade -Select- (Choose one) * Referred by? * N/A -Select- Boots to Business Business Owner Chamber of Commerce Educational Institution Internet Lender Local Economic Development Official Magazine/Newspaper Other Client SBA District Office SBA Web Site SBDC SCORE Television/Radio USEAC VBOC Women's Business Center Word of Mouth -Select- (Choose One) * What is the nature of the counseling you are seeking? * N/A -Select- Business Accounting/Budget Business Plan Buy/Sell Business Cash Flow Management Customer Relations Financing/Capital (Such as applying for a loan or building equity capital) Franchising Government Contracting (including certifications) Human Resources/Managing Employees International Trade Legal Issues (such as Should I Incorporate?) Managing a Business Marketing/Sales (promotion, market research, pricing, etc) Startup Assistance (How do I start a small business?) Tax Planning Technology/Computers eCommerce -Select- * Date Business Started N/A dd-MMM-yyyy (Only Existing Business) * Business Ownership Male N/A | 0 | 100 (Slide for Total Amount of Male Ownership) * Business Ownership Female N/A | 0 | 100 (Slide for Total Amount of Female Ownership) * Do you conduct business online? N/A Yes No * Are you a Home Based Business? N/A Yes No * Are you 8(a) Certified? N/A Yes No * Number of Full-Time Empolyees N/A * Number of Part-Time Employees N/A * Legal Structure N/A -Select- LLC-Limited Liability Company C-Corporation S-Corporation DBA-Doing Business As/Sole Proprietorship Partnership -Select- * For your most recent full business year, what were your: N/A Gross Revenue/Sales: ( In Dollars) * For your most recent full business year, what were your: N/A + Profits / - Losses: (In Dollars) * Confidentiality Agreement and Signature (ALL clients must sign) I request business counseling service from the Small Business Administration (SBA) or an SBA Resource Partner. I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA services. I understand any information disclosed will be held in strict confidence. (SBA will not provide your personal information to commercial entities). I authorize SBA to furnish relevent information to the assigned management counselor(s). I further understand that the counselor(s) agrees not to: 1) recommend goods or services from sources in which they have an interest, and 2) accept fees or commissions developing from this counseling relationship. In consideration of the counselor(s) furnishing management or technical assistance, I waive all claims against SBA personnel and that of its Resource Partners and host organizations, arising from this assistance. SBDC services are not available to individuals or entities that have been debarred or suspended by the federal government. By agreeing to receive assistance from the SBDC with your signature on this form, you are self-certifying that you are not currently federally debarred or suspended and also agree to cease using SBDC services if you become federally debarred or suspended in the future. Use of Information: The information in this form is to be provided by individuals and businesses seeking technical assistance services from the Small Business Administration (SBA) or an SBA Resource Partner. The information is collected to help SBA's continuing improvement of business counseling programs, to ensure effective oversight and management of entrepreneurial development programs and grants, and to meet Congressional and Executive Branch reporting requirements. The form should be submitted at the site of service to the counselor providing the service. Resource Partners will submit information to SBA according to the terms of their notice of award. I permit SBA or its agent the use of my name and address for SBA surveys and information mailings regarding SBA products and services ( Yes No ). * Date-Time N/A dd-MMM-yyyy HH:MM AM/PM * Signature N/A E-Signature Field Clear * Submit ERROR OCCURRED You haven't verified your email yet, click here to receive a verification email. Do not submit confidential information such as credit card details, mobile and ATM PINs, OTPs, account passwords, etc.Report Abuse Powered by This file format is not supported by your browser for preview. OK OK OK OK Retry Cancel That CAPTCHA was incorrect. Your form has been deactivated. Contact support@zohoforms.com for further information. Submitting... Please Wait... Saving... Redirecting to Merchant Website.. Verifying Credit Card Details... Please wait... Loading payment widget... Verification Code Enter the text in the box below Continue Verification mail sent. LINK TO RESUME THIS FORM LATER: Email Link to Send Please enter a valid email address to configure Zoho Sign settings. 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