Cambodian American League of Lowell 60 Middlesex Street Lowell, MA 01852 Tel 978 454-3707 Fax 978 441-1781 info@CambodianAmerican.com www.CambodianAmerican.com APPLICATION FOR MICROENTERPRISE TRAINING PROGRAM INCLUDING FEE DETERMINATION Please print this form, attaching your check in the correct amount, and mail to: Cambodian American League of Lowell, 60 Middlesex St., Lowell, MA 01852 Or you may fill out this form using your computer, sending completed form via email to: info@CambodianAmerican.com and you may mail your check later to: Cambodian American League of Lowell, 60 Middlesex St., Lowell, MA 01852 . To fill out on your computer, right click on the link and save it to your Desktop. From your Desktop you can fill in the required info, save it, and email it to us either as an email attachment or paste it into your email. This form was written using notepad and is a .txt document. 1) LAST NAME: 2) FIRST NAME: 3)STREET ADDRESS: CITY: STATE: ZIP: 4) HOME TELEPHONE: CELL PHONE: 5) WORK TEL: 6) YOUR EMAIL ADDRESS: YOUR WEBSITE: 7) SOCIAL SECURITY NUMBER (IF AVAILABLE): 8) ARE YOU MALE OR FEMALE? 9) DATE OF BIRTH: 10) CITIZENSHIP: (PLEASE CHECK ONE) US: LPR : OTHER:* * PLEASE EXPLAIN : 11) WHAT LANGUAGES DO YOU SPEAK? 12) HOW MANY YEARS DID YOU ATTEND ELEMENTARY SCHOOL? 13) HOW MANY YEARS DID YOU ATTEND HIGH SCHOOL? 14) HOW MANY YEARS DID YOU ATTEND COLLEGE? 15) WHAT DID YOU STUDY IN COLLEGE? 16) DO YOU HAVE A COLLEGE DEGREE? 17) DO YOU OWN A BUSINESS? IF SO, WHAT BUSINESS DO YOU OWN? 18) DO YOU WANT TO START A BUSINESS? IF SO, PLEASE EXPLAIN WHAT BUSINESS YOU HOPE TO START: DETERMINING THE MICROENTERPRISE TRAINING FEE 19) THE FEE FOR MICROENTERPRISE TRAINING IS BASED ON HOUSEHOLD SIZE AND ANNUAL INCOME. FOR EXAMPLE, IF THERE ARE 3 PEOPLE IN YOUR HOUSEHOLD AND YOUR TOTAL FAMILY INCOME DOES NOT EXCEED $33,850 THAN THE TOTAL FEE IS $25. SEE THE MATRIX BELOW TO DETERMINE YOUR FEE. IF YOU WOULD LIKE WE CAN HELP YOU DETERMINE THE FEE. EMAIL US AT: INFO@CAMBODIANAMERICAN.COM AND WE CAN HELP YOU DETERMINE THE FEE. Household Size & Income Matrix 1 2 3 4 5 6 7 8 $25 $15,800 18,050 20,300 22,550 24,350 26,150 27,950 29,800 $50 26,300 30,100 33,850 37,600 40,600 43,600 46,600 49,650 $75 38,100 43,500 48,950 54,400 58,750 63,100 67,450 71,800 $100 38,101+ 43,501+ 48,951+ 54,401+ 58,751+ 63,101+ 67,451+ 71,801+ (Guidelines effective as of March 6, 2002) 20) How many people in your household? 21) What is your annual household income? 22) What is your fee based on number of people in your household and annual household income? I understand that the information contained on this application is complete and accurate to the best of my knowledge and that this application will be retained by the Microenterprise Training Program. I will be expected to provide the program with business and personal financial information for a period of three (3) years. Having carefully read this application, I hereby authorize the release of any of this information with other individuals, agencies and organizations for the purpose of securing funding, training and business financing. Participant/Guardian: Date: