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SBA Form

U.S. Small Business Administration

Counseling Information Form

OMB Approval No.:3245-0324

Expiration Date: 11/30/2010

1. Client Name (Name of the person completing the form/representative of the business)(Last, First, MI)

2. Email

3. Telephone Cell Phone 4. Fax

5. Street Address/PO Box(give business address if currently in business)

6. City 7. State 8. Zip

9. 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 ). 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 18 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.

10. Preferred date & time for appointment

11. Client Signature (type name here to accept terms) 11a. Date

 

12. Race (mark one or more) 13. Ethnicity 14. Gender 15. Do you consider yourself a person with a disability ?
Asian Black or African American Hispanic or Latino Male Yes
American Indian or Alaska Native Not Hispanic or Latino Female No
Native Hawaiian or other Pacific Islander
White
16. Veteran Status 16a.Military Status

 

17. What prompted you to contact us ?(mark all that apply)
SBA District Other Client Chamber of Commerce Other (specify)
Bank Magazine Educational Institution SBA Web site
Lender Business Owner Internet Local Economic Development Official
Television/Radio Newspaper Word of Mouth

 

18. Are you currently in Business ?
Yes No (if no, skip to 28)
19. Name of Company

 

20. Type of Business (choose primary category)

 

21. Business Ownership – What percentage of your business is male
or female ownership ? %Male %Female

 

22. Month & Year Business Started ?
23. Do you conduct business online ?(Yes No )
24. Are you a home based business ? (Yes No ) 24a. Are you Are you 8(a) Certified ?(Yes No )

 

25. Total No. of Employees (full & part time)

 

26. For your most recent full business year,
what were your:
Gross Revenues/Sales $
+Profits/-Loses $

 

27. What is the legal entity of your business ?
Sole Proprietorship Corporation LLC
S-Corporation Partnership
Other (specify)

28. What is the nature of counseling you are seeking ? (choose primary category)

Describe specific assistance requested in the space provided.