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SBDC Request for Counseling Form

Counselor Requested:
Personal Information:
1) First Name: (Person completing form) MI: Last Name: 2) Email:
3) Telephone (Primary): 4) Telephone (Secondary) : 5) Fax:
6) Street Address/PO Box: (give business address if currently in business) City: State: Zip:
.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. permit SBA or its agents 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 the assistance. Please note: The estimated burden for completing this from 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. By completing and returning the Request For Counseling Form (SBA Form 641) by email or by fax, you have authorized an electronic substitute of your written signature on the form.
7) Race: 8) Ethnicity: 9) Gender: 10) Do you consider yourself a person with a disability?
11) Veteran Status: 12) Military Status:  
   
Business Information:
13) What inspired you to contact us?: (Mark all that apply) 14) SBA Client Status: Do you currently have, or do you intend

to apply for any of these SBA programs?

15) Are you currently in business?: 16) Name of Company:
(If "No", skip to question 25)
17) Type of Business: (choose primary category) 18) Business Ownership: (% of your business male or female owned)
Male: Female:
19) Month & Year Business Started? : 20) Do you conduct business online?: 21) Is this a home based business?:
22) Number of Employees: (count yourself) 23) For your most recent full business year: 24) Business Entity Type:
Full Time: Part Time:
Gross Revenue (Sales): Profits (Losses):
25) Area of Assistance Requested: (Mark all that apply)
26) Describe the nature of the counseling you are seeking:

27) Describe the nature of your product of service:

 

Thank you very much for taking time to fully complete this form.

 

By clicking the button below, you agree provisions of this document and wish to request a counseling session.

To reset this application click the button below.

 

 
 
Last Revision: July 24, 2007
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