SBDC Counseling Request Form

Part I: Client Request For Counseling
Date:		History:	One Time Initial

Client Code:		SBA District:

Communication Type:	Face to Face Online Telephone

Client Info
Last Name: First : Initial:
DOB:

Position/Title:		Business Name:

*Street/P.O. Box:
City: State: Zip: County:*

Home Phone:		Business Fax:
Business Phone:		Other Phone:
Email address:		Website:

Business Description:


Client Preferences: No Mailings No Public Releases No Email SBA Impact Survey

Part II: Client/Owner Intake
Race:	Ethnicity:	Gender:
Asian	Hispanic Origin	Male
Black or African American	Not of Hispanic Origin	Female
Native American or Alaska Native	No Reply	No Reply
White	Do you consider yourself a person with a disability?
No Response	Yes No No Reply

Veteran Status:	Non-Veteran Veteran Service-Connected Disabled Veteran No Reply
Military Status:	Member of Reserve or National Guard On Active Duty Not Military

What inspired you to contact us?
1st Stop Business Connection	Educational Institution	Magazine	SBA
Accountant/Attorney	Government Agency	Newspaper	SBDC
Bank	Internet	Other Client	Seminar
Business Owner	ITAC/ITD	PTAC	Word of Mouth
Chamber of Commerce	Local ED Council	Radio/Television	Other

Legal Entity of Business:		Business Status:
C-Corporation	Limited Partnership	Existing Declining	Start-up
General Partnership	Non Profit Corporation	Existing Healthy	No Response
LLC	Sole Proprietorship	Pre-venture/Nascent
LLP	S-Corporation
Foreign	Undecided	Business Start Date:

Type of Business (choose primary category):
Accommodation & Food Services		Manufacturing - Metals & Electronics
Administrative & Support		Mining
Agriculture, Forestry, Fishing & Hunting		Other Services (except Public Administration)
Arts, Entertainment & Recreation		Parcel Delivery & Warehousing
Construction		Professional, Scientific & Technical Services
Finance & Insurance		Public Administration
Educational Services		Real Estate & Rental & Leasing
Health Care& Social Assistance		Retail Trade – Multiple Product Sales
Information		Retail Trade – Single Product Sales
Management of Companies & Enterprises		Transportation and Warehousing
Manufacturing - Food & Textiles		Utilities
Manufacturing - Non-Metal		Wholesale Trade

Business Ownership - What percentage of your business is male or female ownership? %Male: %Female:

NAICS:


Do you conduct business online?		Is this a home based business?
Yes No		Yes No
Is this a commercial bases business?		Is this a new product or technology?
Yes No		Yes No
Do you export?		Do you import?
Yes No		Yes No
Is you business defense related?
Yes No

What is the nature of counseling you are seeking?
No Response		Human Resources
Access to Capital – Debt		Intellectual Property
Access to Capital – Equity		International Trade
Agribusiness		International Trade Country Profiles
Accounting/Budget/Inventory Setup		International Trade Market Research
Business Planning		Inventory Control
Business Start-Up		Legal Issues
Buy/Sell Business		Management/Leadership
Cash Flow Analysis & Management		Market Diversification
Community Dev. Block Grant		Marketing Planning
Commercialization		Operations Analysis & Planning
Computer Systems		Regulatory Compliance
Customer Relations		Small Business Innovation Research
Engineering R&D		Strategic Planning
eVantage		Tax Planning
Federal & State Tech. Program		Technology
Financial Analysis		Women’s Certification
Franchising		Other
Government Contracting
Describe specific assistance requested:


Baseline economic indicators:
Full Time Employees:		Part Time Employees:
Gross Revenue/Sales: (most recent full business year)		Profit/Losses:	+ / -

Preferred date and Time for appointment:
Date:		Time:



I request business counseling service from the Small Business Administration (SBA) or an 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. 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 further understand that the counselor(s) agrees 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 currently 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 10202, Washington, D.C., 20503. OMB Approval (3245-0324). PLEASE DO NOT SEND FORMS TO OMB. I have worked with my Business Advisor to establish and agree to the counseling goals in my file.
I have read and agree to terms above

Part I: Client Request For Counseling

Client Info

Part II: Client/Owner Intake