1. Name of Company:
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2. Your Name(Last,First,Middle):
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| |
4. Street Address:
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9. Governmental Information
W hat elected official represents the area where you conduct
business?
(This information can be filled out when you meet with
a counselor.)
|
| 10. Ethnic Background: |
11. Veteran Status:
Veteran
Vietnam-Era
Veteran
Non-Veteran
Disabled Veteran
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12. Business Ownership Gender:
Male
Female
Dual
Ownership
|
13. SBA Relationship:
A. Have you ever applied for a SBA loan?
Yes
No
B. Did you receive a SBA loan?
Yes
No
If yes, amount? $
|
14. Company Information:
Former SBDC client?
Yes
No
SIC Code (if known)
Annual
Gross Sales
|
15. Are you presently?
Exploring
a business
Starting a new business
Buying an existing business
Already in business
/
mo./year. Started |
16. If in business, is the company
(circle best description below)
Growing
Steady
Declining
Healthy
|
17. Present No. of Employees:
Number
of Full-Time
Number
of Part-Time |
18. Type of Business:
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19. Form of Business:
Sole Proprietorship
Partnership
Undecided
S Corporation
C Corporation
Other
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20. How did you learn of our services?
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21. Check the area of desired assistance:
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22. Please describe how the SBDC
may be of assistance:
|
| Please Read
The Statement Below
(You will be asked to sign this document
when you meet with a counselor.)
I request management assistance from the Small Business Administration
and/or the Small Business Development Center. I understand this assistance
is free of charge. I agree to notify my elected officials of the impact
of this service to the small business community and to cooperate should
I be selected to participate in surveys designed to evaluate SBA/SBDC
assistance services. I authorize SBA/SBDC to furnish information to the
assigned management counselor although I expect that information to be
held in strict confidence by the counselor.
I further understand that nay counselor has agreed not to (1) recommend
goods or services from sources in which the counselor has an interest,
and (2) accept fees or commissions developing from this counseling relationship.
In consideration of SBA's furnishing management or technical assistance,
I waive all claims against SBA personnel, SCORE, SBDC, and host organizations,
SBI and other SBA Resource Counselors arising from this assistance.
| ___________________________________ |
_________________ |
| Signature and Title of Requestor |
Date |
|
|
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