Business Hospital Program Application

This form is for Douglas County Chamber members and Douglas County businesses to indicate interest in one-on-one business assistance through our partner The Business Hospital. Please complete all sections to help us understand your needs and match you with the right support.

Company Information

Company Name *

Owner/Principal *

Role/Title *

Title *

Business Address

Address Line 1 *

Address Line 2

City *

State *

Zip/Postal Code *

Phone *

Primary Contact Email *

Website *

Year business was established *

Years under current ownership *

Entity (LLC, Corp., S-Corp.) *

EIN # *

Do you own your building or facility? *

Yes No

Number of full-time employees *

Number of part-time employees *

Approximate Annual Revenue *

Under 100k Between 100k-500k Between 500k-1M Above 1M

Company's products/services: *

Business Type

Service Nonprofit Retail Manufacturing Technology Other

Please select your business type

If other, please explain below.

Which financial documents does your company prepare annually?

Audit Financial Review Compiled In-House Tax Return Other

Please select all that apply.

If other, please explain below.

What is your company's principal mission? *

Does your company hold any certifications? (Please select all that apply, upload a copy of certificate) *

8(a) Business Development Program (SBA) Georgia Small Business Certification (SBSD) Small Disadvantaged Business (SBD) Minority Business Enterprise (MBE) Women Owned Small Business (WOSB) Women’s Business Enterprise (WBE) None Other

Upload Certifications

Company Product/Service

Company’s current flagship product/service? *

What is the competitive advantage of this product/service (niche)? *

Who are your direct and indirect competitors? *

What are the alternatives to your company’s product/service? *

Why is your company’s product/service superior to others (other than customer service)? *

Risks & Opportunities

What are the top three challenges your business is currently facing? *

What are the greatest risks associated with company’s business? *

What is the biggest growth opportunity for your company? *

Why do you want treatment from The Business Hospital? *

Please describe any specific goals or outcomes you hope to achieve through this assistance:

Areas of Need

1 2 3 4 5 6

Marketing and Branding
1

2

3

4

5

6

Staffing and HR
1

2

3

4

5

6

Legal and Compliance
1

2

3

4

5

6

Business Planning and Strategy
1

2

3

4

5

6

Operations and Efficiency
1

2

3

4

5

6

Financial Management
1

2

3

4

5

6

Scaling and Expansion
1

2

3

4

5

6

Other (please explain below)
1

2

3

4

5

6

Please rank the following areas based on your need primary needs of assistance:

Support Materials

Please provide on a separate document the following support materials:

Upload File: State Registration/Articles of Incorporation

Upload File: Business License (optional)

Upload File: Testimonials from three customers, clients or vendors
All testimonials can be in one document.

TEST

Additional Information

Are you a Chamber Investor? *

Yes No

Investors are paying members of the Chamber. Introductory Members are not Investors.

Have you previously received business assistance? *

Yes No

If yes, please explain below.

Consent and Agreement *

I agree to be contacted by the Douglas County Chamber for follow-up on my application.