Do you have a serious interest in creating your own business?*

 Yes No

Would you be able to create a new business within the next 12-24 months?*

 Yes No

Have you already taken entrepreneurial initiatives?*

• Taking courses on entrepreneurship?  Yes No
• Contacting the U.S. Small Business Administration or other business/entrepreneurial organizations?  Yes No
• Other?  Yes No

__________________________________________________________

Name*

Address:

Street*

City*

State*

Zip*

Telephone*

Email*

Please indicate any dietary restrictions:

The meeting is for people 50 and older (50+) who have an interest in creating their own business. Is this of interest to you?

 Yes - If yes, please explain below No

Please indicate any particular information or guidance you would like to obtain from the meeting.

What has been your primary work in the past?*

Have you ever created your own business?*

 Yes - If yes, please describe below. No

Please indicate whether your spouse will join you. *

 Yes - If yes, please provide name below. No

Please select one of the following for your age range:*

 50-55 56-60 61-65 66-70 71-75 75+

* Required Field

Payment Options

If Credit Card is selected, you will be redirected to an online payment page after clicking the send button.

 Credit Card Check

There will be a charge of $35 for each participant, which will cover spouses. Payment by checks should be made payable to the Center for Productive Longevity, must be received not later than September 1 to ensure your participation in this event.