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6. Wyoming County's Business Startup Program -KAUFFMAN FASTTRAC® Registration
9. Registrant Information
11. Name*
13. Email Address*
14. Phone Number*
16. Address*
18. City*
19. State*
20. Zip Code*
22. Business Information
24. What stage is your business?*

    1. Start-up (Concept to 1 year in business)
    2. Early Stage (1 to 5 years in business)
26. Please describe your business without sharing proprietary information or trade secrets
28. Is your business already established?

    1. Yes
    2. No
30. If yes, please complete the following information.
32. Business Name
33. Business Address
35. City
36. State
37. Zip Code
39. Business Phone Number
40. Email Address
42. Business Website URL
44. If No, please list the location where you would like to establish your business.
46. By submitting your registration you agree to the Terms and Conditions
    Participant Code of Conduct; Privacy Policy; Photo, Video, Audio Consent and Release
48. Easy access to the internet & familiarity with Microsoft Word & Excel is recommended but not mandatory. For questions or to opt-out of the photo, video, and audio consent and release please contact Jennifer Tyczka at jtyczka@wycoida.org or 585-786-3764.
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52. 1. Receive an email copy of this form.
53. Email address

    This field is not part of the form submission.

54. Submit

* indicates a required field