Small Business Off Campus Work Study Eligibility Questionnaire

This questionnaire is for Wisconsin small businesses to determine their eligibility as a prospective UW-Madison Federal Work-Study partner.

Complete Name of Business*
Phone Number of Business*
Contact Name (please list the first and last name of the person you want us to reach out to about work study eligibility)*
Email Address (please list the email you want us to reach out to about work study eligibility)*
Address of Business*
Street Address Address Line 2 City State ZIP Code
Name of Business Owner*
First Last
Business Owner Email Address*
Address of Business Owner (if different from above)
Street Address Address Line 2 City State ZIP Code
Please supply your 6 digit North American Industry Classification System (NAICS) code.*

If you are unsure of your code, please reference the NAICS code list here:https://www.ecfr.gov/cgi-bin/text-idx?SID=eddd5ca2c2b470eb216e831604ca0fc9&mc=true&node=pt13.1.121&rgn=div5#se13.1.121_1201
Please list your annual average revenue using the past 3 years.*
Please list the number of employees you have had for the past 12 months. (Please include both full and part time employees in this count)*
My organization is a part of the SuccessWorks Community Justice Internship Program?*
- Yes
- No
Is your business classified as a benefit corporation?*
- Yes
- No
What is the purpose and general function of this business?*
For what types of jobs do you intend to hire Work-Study Program students?*
What groups, populations and/or agencies does your business serve?*
What need(s) in the community does your business serve?*
Are there any membership requirements? (Please be specific)*
Is this position being created as a result of response to a community need, a newly created position, or some other reason?*
Please provide any additional information, which would aid us in determining your eligibility to hire Work-Study students.*
Acknowledgment*
I certify the information provided above is accurate to the best of my knowledge.