Small Business Development Center Network
REQUEST FOR COUNSELING

1. NAME OF COMPANY: (if already in business) 3. FIRST NAME:

2. TITLE:
 4. LAST NAME:

 
4.

CONTACT INFORMATION
 

Business Phone: 

  
Home Phone: 
Fax Number: 
 
Cell Phone: 
Email Address: 

     
 
 
5.
STREET ADDRESS:

 6. CITY:
    		7. COUNTY:
   
8. STATE:
    		9. ZIPCODE:
   
10. WHAT TYPE OF ASSISTANCE DO YOU NEED? (Please be specific.)
     
11. HOW DID YOU LEARN OF THE Small Business Development Center:
 
a. Word of Mouth e. Internet j. Trade Show
b. Bank f. Radio k. Yellow Pages
c(1.). Newspaper - article g. Television l. Other Business Assistance Org.
c(1.). Newspaper - column h. Magazine m. Existing SBDC Client
d. Chamber of Commerce i. SBA n. Other:
           
 
 
 
 
 
 
12. IF YOU ARE CURRENTLY IN BUSINESS, START DATE:
13. TYPE OF BUSINESS:
14. BUSINESS CLASSIFICATION: (Check one)                         15. FINANCIAL AND EMPLOYEE DATA:
  a. Retail d. Manufacturing

Date of Last Annual
Financial Statement

 
  b. Service e. Construction
Gross Sales
 
  c. Wholesale    
Full-Time Employees
  
         
Part-Time Employees
  
   
16. INTERNATIONAL
       TRADE:

17. BUSINESS
       ENTITY:

   

18. BUSINESS
       OWNERSHIP /
       GENDER:

 

19. AGE OF OWNERS:
a. Yes a. Sole Proprietorship   a. Male   a. Under 21 d. 40-49
b. No  b. Partnership   b. Female   b. 21-29 e. 50-59
  c. Corporation   c. Male/Female   c. 30-39 f. 60 +
  d. Other              
             
20. VETERAN STATUS:  

21. YEARS IN FIELD:

   

22. EDUCATIONAL LEVEL:

 
  a. Veteran   a. Less than one year   a. Not a high school grad   d. College degree
  b. Vietnam- Era   b. One to three years   b. High School graduate   e. Graduate school
  c. Disabled   c. Three to five years   c. Some College   f. Graduate degree
  d. Non-Veteran   d. Over five years            
             
23. HANDICAPPED:    a. Yes  b. No
24. ETHNIC BACKGROUND: 25. SBA PROGRAMS ACCESSED:
  Race:       a. Borrower e. Cert. of Competency
  a. American Indian/Alaskan Native     b. Applicant f.  8(a) & Borrower
  b. Asian     c. 8(a) Client g. 8(a) & Surety Bond
  c. Black or African     d. Surety Bond h. Not an SBA Client
  d. Native Hawaiian/Pacific Islander            
  e. White   26. Would you like to receive notices of SBDC
services, training and events?:
Ethnicity: Yes No
a. Hispanic Origin    
  b. Not of Hispanic Origin