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GROW Nebraska Membership

I understand that my membership is good for one year and will be due the month I joined the following year. All information below provided to GROW Nebraska is kept in strictest confidence. Much of the funding that allows GROW to develop new programs comes from grants. Please provide the following information so we can provide full statistics to our grantors, with guaranteed anonymity for our members, on the businesses we serve and the growth that they achieve.
*Date:
*Name of Business:
*Date Business Started:
*Physical Address:
*Mailing Address:
*City:
*State:	AK-Alaska AL-Alabama AR-Arkansas AZ-Arizona CA-California CO-Colorado CT-Connecticut DC-District of Columbia DE-Delaware FL-Florida GA-Georgia HI-Hawaii IA-Iowa ID-Idaho IL-Illinois IN-Indiana KS-Kansas KY-Kentucky LA-Louisiana MA-Massachusetts MD-Maryland ME-Maine MI-Michigan MN-Minnesota MO-Missouri MS-Mississippi MT-Montana NC-North Carolina ND-North Dakota NE-Nebraska NH-New Hampshire NJ-New Jersey NM-New Mexico NV-Nevada NY-New York OH-Ohio OK-Oklahoma OR-Oregon OT-Other PA-Pennsylvania RI-Rhode Island SC-South Carolina SD-South Dakota TN-Tennessee TX-Texas UT-Utah VA-Virginia VT-Vermont WA-Washington WI-Wisconsin WV-West Virginia WY-Wyoming   *ZIP:
*County:	Select Adams Antelope Arthur Banner Blaine Boone Box Butte Boyd Brown Buffalo Burt Butler Cass Cedar Chase Cherry Cheyenne Clay Colfax Cuming Custer Dakota Dawes Dawson Deuel Dixon Dodge Douglas Dundy Fillmore Franklin Frontier Furnas Gage Garden Garfield Gosper Grant Greeley Hall Hamilton Harlan Hayes Hitchcock Holt Hooker Howard Jefferson Johnson Kearney Keith Keya Paha Kimball Knox Lancaster Lincoln Logan Loup McPherson Madison Merrick Morrill Nance Nemaha Nuckolls Otoe Pawnee Perkins Phelps Pierce Platte Polk Red Willow Richardson Rock Saline Sarpy Saunders Scotts Bluff Seward Sheridan Sherman Sioux Stanton Thayer Thomas Thurston Valley Washington Wayne Webster Wheeler York Other
*Business Phone:	( )   -
Cell Phone:	( )   -
Fax:	( )   -
E-mail:
Web Site:
Date Web Site Launched:
*Owner Name:
*Owner Gender:	Male Female
*Owner Date of Birth (MM-DD-YYYY):
Primary Contact Person if different:
Primary Contact E-mail:
*Do you have a Nebraska Tax ID Number?:	Yes No
*How did you find out about us?:	Referral GROW Web Site Radio Newspaper REAP Other:
If referred, who referred you?:
*Do you have a business plan?	Yes No
Do you have a retail store front?	Yes No
Social Networking GROW Nebraska sees the growth in social networking and therefore asks members and potential members to supply any social networking sites that they are using with their business. We ask that you please supply ONLY sites that relate to your business. Please do not list any personal blogs, Flickr, YouTube, Twitter, Google+ or Facebook accounts.
Blog Address:
Facebook Business Page Name:
Google+ Business Page Name:
Twitter Address:
Flickr Photostream Name:
LinkedIn Profile:
YouTube Channel:
Please choose the category you feel your business fits in. (You can be listed in multiple categories online, but additional listings are not available in the printed piece.)
Please Select the Category Which Best Describes Your Business (You May Select More Than One):	Bath & Body/Candles Fine Art Gourmet Food & Beverage Home Jewelry & Wearables Music & Books Outdoor & Pet Supplies Service Tourism Resource Providers & Media
I verify I have products that qualify as:	Organic Natural No Sugar Added Sugar Free Gluten Free Salt Free MSG Free
Is your product line produced in Nebraska?:	Yes No
If not, where is it produced?
Current Sales Methods:	Retail Wholesale eBay eStore (on own Web site) Consignment Fundraising
Please describe your business:
If you would like to offer a year-round discount on your product or service to other GROW members, please list it here.
*Is your business home based?:	Yes No
*How many people are in your household?:	Please Select 1 2 3 4 5 6 7 8 9 10+
*How many full-time people do you employ, including yourself?:
*How many part-time people do you employ, including yourself?:
*What were your gross annual sales last year?:	Please Select $0-10,000 $10,001-25,000 $25,001-50,000 $50,001-100,000 $100,001-150,000 $150,001-$500,000 $500,001-$1,000,000 $1,000,001-$2,500,000+
*Did you claim business income on your tax return?:	Yes No
*Are you a veteran?	Yes No
*Are you on public assistance?:	Yes No
*Are you disabled?	Yes No
*What is your ethnic origin?	Please Select Black American Indian White Hispanic Asian Other
*What is your annual gross household income?	Please Select $0-29,000 $29,000-34,000 $35,000-39,000 $39,000-44,000 $44,000-49,000 $49,000-54,000 $54,000-59,000 $59,000-64,000 $69,000-74,000 $75,000+
*Has your business created any new jobs in the past year?:	Yes No
*Does your business sell domestically outside of Nebraska?	Yes No
*If yes, what percentage?
*Does your business sell outside of the United States?	Yes No
*If yes, what percentage?
*Did your business profitability increase last year?:	Yes No
*What makes your company different from your competition?
*Tell us about your family:
GROW Nebraska periodically takes photographs and video clips at events that we sponsor. If you would like to opt-out of the use of your picture for promotional purposes, please check the box below. This includes promotion in printed materials, Facebook, and online.
	I prefer not to have my photo used for promotions.
What level should I choose? For more information on our levels of membership, please click here. Most service members choose basic. If you are interested in only being in one store (Kearney, Grand Island, Omaha or eCommerce/eBay (perishable items only) ) the basic plus one store option is best suited for you. If you would like to be in two or more retail locations, the bundle membership will suit you best. If you have questions please feel free to contact us at (402)742-3121.
*Level of Membership:	Basic - $19/month Basic - $175/year Basic + 1 Store - $25/month Basic + 1 Store - $250/year Bundle - $35/month Bundle - $325/year Student - $60/year Non-Profit - $60/year Senior (70+) - $60/year
If you are interested in retail stores, which stores are you interested in?	Kearney Grand Island Omaha (Eppley Airfield) eBay/eCommerce (perishable items only) eBay