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SBDC Form 641, Part III

Please fill out all applicable fields of the form and submit.

36a. Date Counseled (mm/dd/yy)
36b. History
37. Case Manager's Name
38. Did counseling received result in starting business?	Yes No
39. Number of people attending this session (answer during initial counseling session only).
40. Counselor Name
41a. Communication Type
41b. Language Used	Other
42. Client Name	First Middle Last
43. Email
44. Telephone	Primary Secondary
45. Fax
46. Streed Address / P.O. Box
47. City
48. State / 49. ZIP	/ -
49a. County
50. Business Status	(If Pre-venture selected, skip to 53)
51. Company Name
52. Month & Year Business Started (mm/yy)
53a. What is the nature of the counseling you provided to the client?
No Resonse Access to Capitol - Debt Access to Capital - Equity Agribusiness Accounting/Budget/Inventory Setup Business Planning Business Start-Up Buy/Sell Business Cash Flow Analysis & Management Community Dev. Block Grant Commercialization Computer Systems Customer Relations Engineering R&D eVantage Federal & State Tech. Program Financial Analysis Franchising Government Contracting Human Resources	Intelectual Property International Trade International Trade County Profiles International Trade Market Research Inventory Control Legal Issues Management/Leadership Market Diversification Marketing Planning Operations Analysis & Planning Regulatory Compliance Small Business Innovation Research Strategic Planning Tax Planning Technology Women's Certification Other
Describe specific assistance requested in the space provided.
53b. What assessment tools did you use during counseling?
Enterprise Enterprise - Performance Benchmarking Enterprise - IQa Enterprise - Quick View Environmental Environmental - Energy Environmental - Waste Reduction Financial Financial - Bi-Far High Impact Financial - FISCAL	Grants - SBIR Readiness Grants - STTR Readiness Human Resources Information Technology International Trade - Export Readiness Lean Marketing Quality - ISO/TS 16949 Other
54a. Prep Hours
54b. Contact Hours
54c. Travel Hours
55a. Assessment
55b. Action
55c. Agreement
56a. Updated Economic Indicators
Current SBA Loans
Current Non SBA Loans
Current Gross Sales
Current Export Sales
Current Government Contracts
Current Equity
Current Cost Avoidance
Current Employees
56b. SBA or Resource Partner Service Contributed to the Following:
No. of Government Contract/Subcontracts Received
No. of Certification Received (SDB, HUBZone, local, etc.)

Logan/Hocking County
Logan-Hocking County Chamber of Commerce
4 East Hunter Street
Logan, Ohio
(740) 385-6836

Pomeroy/Meigs County
Meigs County Chamber of Commerce
238 West Main Street
Pomeroy, Ohio
(740) 992-5005

Corning/Perry County (Southern)
Southern Perry Incubation Center for Entrepreneurs (SPICE)
PO Box 349
112 North Valley Street
Corning, Ohio

New Lexington/Perry County
Hocking College Outreach Center

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