Buisness Name:
First Name:		Last Name:
Partner First Name:		Last Name:
Partner Phone #:
Address:
City:		State:		Zipcode:
Work Phone:		Home Phone:
Fax:		Cell:
E-Mail:
Type of Client:	Face to Face Online Telephone
Website:
Type of Business:	Retail Service Wholesale Manufacturing Construction Not in Business Yet
Business Ownership:	Female Female/Female Partnership Male Male/Female Partnership Male/Male Partnership
Ethnic Group:	American Indian Asian Black Eskimo/Aleutian Hispanic Mexican American Native Hawaiian or Pacific Islander Puerto Rican Undetermined White
Veteran Status:	Non-Veteran Veteran Service-Disabled Veteran On Active Duty Member of Reserve of National Guard
Handicapped:	Yes
Month & Year Business Started? Home Based Business Conduct Business Online?
Total No. of Employees (full & part time)
For your most recent full business year, what were your:
Gross Revenues/Sales	$
+Profits/-Losses:	$
What is the legal entity of your business? Sole Proprietorship Corporation LLC S-Corporation Partnership Other (Sepecify)
Type of Business (choose primary category) Professional Scientific & Technical Services Mining Manufacturing Real Estate & Rental & Leasing Management of Companies & Enterprises Utilities Finance & Insurance Health Care & Social Assistance Agriculture Forestry Fishing & Hunting Information Wholesale Trade Accommodation & Food Services Administrative & Support Construction Public Administration Arts Entertainment & Recreation Waste Management & Remediation Services Retail Trade Educational Services Transportation & Warehousing Other Services (except Public Administration)
Interested in:	Import Only Export Only Both Import/Export Neither Import/Export
Referred to SBDC by:
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.