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Counseling Information Form


PART I: Client Request for Counseling


An * indicates a required field.

Last Name: (Name of the person completing the form/representative of the business)*
First Name:*
Middle Initial:
E-mail:
Telephone (Primary):*
Telephone (Secondary):
Fax:
Street Address/PO (give business address if currently in business):*
City:*
State:*
ZIP:*
+4

I request business counseling service from the Small Business Administration (SBA) or SBA Resource Partner. I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA services. I permit SBA or its agent the use of my name and address for SBA surveys and information mailings regarding SBA products and services.

Permission Yes    No   

I understand that any information disclosed will be held in strict confidence. (SBA will not provide your personal information to commercial entities.) I authorize SBA to furnish relevant information to the assigned management counselor(s). I futher understand that the counselor(s) agree not to: 1) recommend goods or services from sources in which he/she has an interest, and 2) accept fees or commissions developing from this counseling relationship. In consideration of the counselor(s) furnishing management or technical assistance, I waive all claims against SBA personnel, and that of its Resource Partners and host organizations, arising from this assistance.


Please note: The estimated burden for completing this form is 3 minutes. You are not required to respond to any collection information unless it displays a current valid OMB approval number. Comments on the burden should be sent to: U.S. Small Business Administration. 409 3rd Street SW, Washington DC 20416, and to: Desk Officer SBA, Office of Management and Budget, New Executive Office Building, Room 10203, Washington, D.C., 20503. OMB Approval (3245-0324). PLEASE DO NOT SEND FORMS TO OMB.

Perferred date for appointment
Perferred time for appointment
I have reviewed and agree to the above terms and conditions:* I agree   
Date:

Part II: Client Intake (to be completed by all Clients)

Race: Asian
Black/African American
Native American/Alaska Native
Native Hawaiian/Pacific Islander
White
Ethnicity Hispanic Origin    Not of Hispanic Origin   
Gender: Male    Female   
Do you consider yourself a person with a disability? Yes    No   
Veteran Status Non-Veteran
Veteran
Service-Disabled Veteran
Military Status: On Active Duty
Member of Reserve or National Guard
What inspired you to contact us? (mark all that apply) SBA
Bank
Business Owner
Television/Radio
Other Client
Magazine
Internet
Newspaper
Chamber of Commerce
Educational Institution
Local Economic Develpoment Official
Word of Mouth
Other (specify)
Other: (What inspired you to contact us?)
Is the client currently in business? Yes    No   
Name of Company
Type of Business (choose primary category) Mining
Utilities
Information
Construction
Retail Trade
Manufacturing
Finance & Insurance
Wholesale Trade
Public Administration
Educational Services
Real Estate & Rental & Leasing
Type of Business (Cont) Health Care & Social Assistance
Accommodation & Food Services
Arts, Entertainment & Recreation
Transportation & Warehousing
Professional, Scientific & Technical Services
Management of Companies & Enterprises
Agriculture, Forestry, Fishing & Hunting
Waste Management & Remediation Services
Other Services (except Public Administration)
Ownership Percentage Male:
Ownership Percentage Female:
Month & Year Busness Started?
Do you conduct business online? Yes    No   
Is this a home based business? Yes    No   
Total No. of Employees (full & part time)
For most recent business year, what were your gross revenues/sales?
For most recent business year, what were your profit (losses)?
What is the legal entity of your business? Sole Proprietorship
Corporation
LLC
S-Corporation
Partnership
Other (specify)
Other - (What is the legal entity of your business?)
What is the nature of counseling you are seeking? (Choose primary category) Start-up Assistance (How do I start a small business?)
Business Plan
Financing/Capital (such as applying fro a loan, building equity capital)
Managing a Business
Human Resources/Managing Employees
Customer Relations
Business Accounting/Budget
Cash Flow Management
Tax Planning
Marketing/Sales (promotion, market research, pricing, etc.)
Government Contracting (including certifications)
Franchising
Buy/Sell Business
Technology/Computers
eCommerce (using the Internet to do business)
Legal Issues (such as, Should I incorporate?)
International Trade
Describe specific assistance requested in the space provided.