North Texas Small Business Development
Centers SBDC Client Intake Form
CLIENT NAME (Last, First, MI)
EMAIL
POSITION
Owner/Sole Proprietorship Employee President Vice-President Partner
Other: ______________________________________________
WORK PHONE CELL PHONE
HOME PHONE FAX
MAILING ADDRESS
GENDER
Male
Female
RACE (mark one or more)
Asian
Native Hawaiian or Pacific Islander
Black or African American
Native American or Alaska Native
White
ETHNICITY
Non-Hispanic
Hispanic
VETERAN STATUS
Non-Veteran
Service-Disabled
Veteran Veteran
RESERVIST STATUS
None
National Guard
National Guard - Active Duty
COMPANY INFORMATION
Export Countries: _______________________________________________________________________________________________________________
WHAT PROMPTED YOU TO CONTACT US (REFERRED FROM)
Advertising/Marketing
Chamber of Commerce
Client/Word of Mouth
College/University
Email
Media/TV/Radio
Lender
Local EDC
News Outlet
SBA Network
SBDC
Training Event/Conf.
Male
Female
Male/Female Owners
BUSINESS SIZE
Disadvantaged - Small
Large
Minority Owned - Small
Other Small
BUSINESS LEGAL
ENTITY
Yes
No
DO YOU
CONDUCT YOUR
BUSINESS ONLINE?
Yes No
8 (A) CERTIFIED
Yes
SBA RELATIONSHIP
TYPE OF BUSINESS
Manufacturing Wholesale Construction Retail Services Other:______________________________
PRODUCTS/SERVICES: _________________________________________________ NAICS CODE(S):
_________________________________________
(SBDC staff can assist with NAICS code for your business)
WHAT ARE YOUR TOTAL NUMBER OF EMPLOYEES
How many are engaged in the exporting aspect of the business?
FOR THE MOST RECENT FULL BUSINESS YEAR, PLEASE PROVIDE
North Texas SBDC Revised SBA Form 641Previous Editions are Obsolete
Revision 1 -- 2015-2016
CITY, STATE, ZIP CODE
COMPANY NAME (IF APPLICABLE) WEBSITE
Reservist
Reservist - Active Duty
DO YOU HAVE
A DISABILITY?
Yes
No
CURRENTLY IN BUSINESS?
Yes Indicate Month/Day/Year established business
_________ / __________ /__________
No
If in business but you want to explore a new business, Please specify the area of interest:
_____________________________________________________
If in business, are you currently EXPORTING?
Yes, Please indicate the Countries below.
No
Not yet but interested
PHYSICAL ADDRESS OF BUSINESS
CITY, STATE ZIP CODE
Website
Social Media (please list)
__________________________________
BUSINESS OWNERSHIP
Business ownership gender
Sole Proprietorship
Partnership
S-Corporation
LLC
Corporation
HOME-BASED?
No
Applicant
Borrower
COC
Procurement Assistance
Technical Assistance
___________ Full Time
____________ Part Time
_______________________________________________________________
Gross Revenue/Sales (GRS) $_________________________________
+Profits/-Losses $_____________________________________________
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. SBDC services are not available to individuals or entities that have been debarred or suspended by the
federal government. By agreeing to receive assistance from the SBDC with your signature on this form, you are self-certifying that you are not currently
federally debarred or suspended and also agree to cease using SBDC services if you become federally debarred or suspended in the future.
CLIENT SIGNATURE
DATE
click to sign
signature
click to edit
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