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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 Impact 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.