OMB Approval No.:3245-0324
Expiration Date: 10/31/2020
U.S. Small Business Administration
Counseling Information Form
Client Number:
Location Code:
Initials of Data Inputter:
SBA Form 641 (
10/24/2017)
1
. Name of the Office Providing the Service _______________________________1a. Type of Client:
Face to Face Online
2
. City/State of Office Location_________________________
Telephone
PART I: Client Request for Counseling
3
.
Client Name
(Name of the person completing the form/representative of the business)
(Last, First, MI)
4. Email
5
.
Telephone 6. Fax
Primary Secondary
7. Street Address/PO Box
(give business address if currently in business
) 8. City 9. State 10. Zip
+4
11
.
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.
Use of Information: The information in this form is to be provided by individuals and business seeking technical assistance services from the Small Business Administration
(SBA) or an SBA Resource Partner. The information is collected to help SBA's continuing improvement of business counseling programs, to ensure effective oversight and
management of entrepreneurial development programs and grants, and to meet Congressional and Executive Branch reporting requirements. The form should be submitted at
12. Preferred date & time for appointment
Date: Time:
13. Client Signature Date:
PART II: Client Intake (to be completed by all Clients)
14
.
Race
(mark one or more)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
15. Ethnicity
Hispanic or Latino
Not Hispanic or
Latino
16.Gender
Male
Female
17. Do you consider
yourself a person with
a disability
?
Yes No
18. Veteran Status
Service-Disabled Veteran
Member of the Reserve
19. Referred by?
(Mark all that apply)
SBA District SBDC Other Client
Lender
SCORE
Educational Institution
Business Owner
WBC
Local Economic Development Official
SBA Web site
VBOC
Chamber of Commerce
Internet (please indicate website)
20a. Are you currently in business?
Yes No
(if no, skip to 30)
21. Name of Business
22. 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)
23. Business Ownership
– What percentage of
your business is male or female owned?
__________% Male__________% Female
24. Date Business
Started?(MM/YYYY)
25. Do you conduct
business online?
Yes No
26a. Are you a home based business
26b. Are you 8(a) certified?
Yes
No
Yes
No
27a. Total No. of Employees
(full & PT)
28a. For your most recent full business year, what
were your:
Gross Revenues/Sales $
+Profits/-Losses $
29. What is the legal entity of your business?
Sole Proprietorship Corporation LLC
S-Corporation Partnership
Other (specify) ________________________________
30. What is the nature of counseling you are seeking?
(Choose primary category)
Start-up Assistance (How do I start a
small business?)
Business Plan
Financing/Capital (such as applying
for a loan, building equity capital)
Managing a Business
Human Resources/
Managing Employees
Customer Relations
Business Accounting/
Budget
Cash Flow Management
Marketing/Sales (promotion, market
research, pricing, etc.)
Government Contracting (including
certifications)
Franchising
Buy/Sell Business
Technology/Computers
eCommerce (using the
Internet to do business)
Legal Issues (such as,
Should I incorporate?)
International Trade
Tax Planning
Describe specific assistance requested in the space provided. _____________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Television/Radio
Magazine/Newspaper
Word of Mouth
Other (specify)
20b. If yes, are you currently exporting?
If yes to 20b, please go to Appendix A on page 3 to indicate the markets to which your company currently exports (mark all that apply).
27b. Of total employees, how many are
engaged in the exporting aspect of your
business: (Full & PT)
28b. Amount of your Gross Revenues/Sales
related to exporting $
the site of service to the counselor providing the service. Resource Partners will submit information to SBA according to the terms of their notice of award.
Yes
No
Veteran
No military, Reserve, or
National Guard service
Active Duty
Member of the National Guard
Spouse of Military Member
USEAC
Boots to Business
Ohio SBDC at Terra State Community College
