Part I: Client Request
for Counseling |
| 1a. Date |
|
| 1b. History |
|
| 2a. Center Code |
|
| 2b. SBA District |
|
| 3. Client Communication Type |
|
| 4. Client Name |
Last
First
Middle
|
| 5. Email |
|
| 6. Telephone |
Primary
Secondary
Mobile
|
| 7. Fax |
|
| 8. Street Address/PO Box |
|
| 9. City |
|
| 10. State / 11. ZIP |
/
-
|
| 11b. County |
|
| 12. 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 (
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 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. |
| 13. Preferred date & time for appointment |
Date
Time
|
| 14. I Agree to the Terms? |
Yes
No
|
Part II: Client/Owner Intake |
| 15. SBA Client Relationship |
8(a) Client
Applicant
Borrower
COC
Surety Bond
No Response |
| 16. Race |
Asian
Black or African American
Native American or Alaska Native
Native Hawaiian or
other Pacific Islander
White
No Response |
| 17. Ethnicity |
Hispanic Origin
Not of HIspanic Origin
Somalian
No Response |
| 18. Gender |
|
| 19. Do you consider yourself a person with a disability? |
Yes
No |
| 20a. Veteran Status |
|
20b. Military Status
|
| 21. What inspired you to contact us? |
1st Stop Business Connection
Accountant/Attorney
Advertising/Magazine/Newspaper
Bank
Business Owner
Chamber of Commerce
Educational Institution
Government Agency
Local ED Council
Internet |
ITAC/ITD
Other Client
PTAC
Radio/Television
SBA
SBDC
Seminar
Word of Mouth
Other |
| 22. Business Status |
(If Pre-venture selected, skip to 34) |
| 23. Company Name |
|
| 24. Month & Year Business Started (mm/yy) |
|
| 25. What is the legal entity of your business? |
C-Corporation
General Partnership
LLC
LLP
Limited Partnership
Non Profit Corporation
Sole Proprietorship
S-Corporation |
Foreign C-Corporation
Foreign General Partnership
Foreign LLC
Foreign LLP
Foreign S-Corporation
Foreign Sole Proprietorship
Foreign Limited Partnership
Foreign Non Profit Corporation |
| 26. Business Ownership - What percentage of your business
is male or female ownership? |
Male
%
Female
% |
| 27. Type of Business (choose primary category) |
Accommodation & Food Services
Administrative & Support
Agriculture, Forestry, Fishing
& Hunting
Arts, Entertainment & Recreation
Construction
Finance & Insurance
Educational Services
Health Care & Social Assistance
Information
Management of Companies &
Enterprises
Manufacturing |
Mining
Other Services
(except Public Administration)
Professional, Scientific &
Technical Services
Wholesale Trade
Public Administration
Real Estate & Rental & Leasing
Retail Trade
Transportation & Warehousing
Utilities
Waste Management &
Remediation Services
|
| NAICS
|
Breifly describe your business/product
|
| 28. Do you conduct business online? |
Yes
No |
| 29. Is this a home based business? |
Yes
No |
| 30. Is this a commercial based business? |
Yes
No |
| 31. Is this a new product or technology? |
Yes
No |
| 32a. Do you export? |
Yes
No |
| 32b. Do you import? |
Yes
No |
| 33. Is your business defense related? |
Yes
No |
| 34. What is the nature of counseling you are seeking? |
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
|
| 35. Baseline Economic Indicators |
| Current Loans |
|
| Current Gross Sales |
|
| Current Export Sales |
|
| Current Government Contracts |
|
| Current Equity |
|
| Current Cost Avoidance |
|
| Current Employees |
|
|
|
