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
Fremont, Ohio
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)
2
Part III: Counselor Record
31
.
Client Name
(please use the same name from original 641 Part 1)
(Last, First, MI)
32. Email
33
.
Telephone 34. Fax
Primary Secondary
35. Street Address /P.O. Box 36. City 37. State 38. Zip
+4
39a. Is the client currently in business?
Yes No
(if no, skip to 44)
40. Date Business
Started?
41a. Total No. of Employees: (Full & PT)
42a. As of the most recent full business year, what were the client's annual:
Gross Revenues/Sales $_____________________
+Profits/-Losses $
43. SBA or Resource Partner Service Contributed to the Following: (Mark all that apply)
Certifications
8(a)
SBIR
Hubzones
Micro loan
SDB
Other (SBIR, SBIC, 7(a) 504, etc)
Other (specify state, local, etc)
44. What was the nature of the counseling you provided the client?
(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
Tax Planning
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
Please specify other counseling provided.
46.
Type of Session
Face to Face Online Update
Telephone Prep
47. Language(s) Used
English
Spanish
Other (specify)
48. History
New Case
Follow-up
One Time
49. Date Counseled
50. Counselor(s) Name (If multiple counselors, list lead counselor first and separate
each additional counselor name by a semi-colon):
51. Contact Hours
Total contact hours
that a client received
51b. Prep Hours
Total amount of
preparation spent by all
counselors for a client
52 Did more than one Counselor participate in this counseling session? Yes__ No__. If yes, how many counselors ________?
53. Counselor’s Notes:
SBA Loan Amount $
Funding Source:
39b. Is the client currently exporting?
If yes, please turn to Appendix A on page 3 to indicate the markets to which your client currently exports (mark all that
apply).
41b. Of total employees, how many are engaged in
the exporting aspect of client's business?:
(Full & PT)
42b. As of the most recent full business year, how much of your client's Gross
Revenues/Sales were related to exporting?
$
Non-SBA Loan Amount $
Amount of Equity Capital Received $
No. of Government Contracts/Subcontracts
Annual Value of Government Contracts/Subcontracts Received
$
SBA Financial Assistance
Export Express
Export Working Capital Loan
Community Advantage
45. Referred Client to (mark all that apply):
WBC
SCORE
SBDC
State Trade Agency
USEAC
SBA District Office
Dept of Agriculture
OPIC
Export/Import Bank
Dept of Commerce
Dept of State
U.S. Trade & Development Agency
51c.Travel Hours Total amount of time it takes to travel to a client's location for counseling
No Yes
(MM/YYYY)
VBOC
PTAC
Other
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:
Appendix A to Questions 20b. & 39b.
If your company is currently exporting, please indicate the countries to which your company exports: (Mark all that apply)
Afghanistan
Bahrain
Bangladesh
Belarus
Bhutan
Brunei
Burma
Cambodia
China
East Timor
Georgia
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Lebanon
Macau
Malaysia
Maldives
Micronesia
Mongolia
Nepal
Oman
Pakistan
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Tajikistan
Taiwan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Congo
Democratic Republic of Congo
Cote d'Ivoire
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Guinea
Guinea-Bissau
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Anguilla
Antigua & Barbuda
Aruba
Bahamas
Barbados
Virgin Islands (British)
Cayman Islands
Cuba
Dominica
Dominican Republic
Grenada
Haiti
Jamaica
Montserrat
Netherlands Antilles
St. Kitts and Nevis
St. Lucia
St. Vincent and Grenadines
Trinidad and Tobago
Belize
Costa Rica
El Salvador
Guatemala
Honduras
Nicaragua
Panama
Europe
Austria
Azerbaijan
Albania
Armenia
Belgium
Bosnia-Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Finland
France
Germany
Greece
Hungary
Iceland
Ireland
Italy
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
Serbia
Slovak Republic
Slovenia
Spain
Sweden
Switzerland
Turkey
Ukraine
United Kingdom
Vatican City
Bermuda
Mexico
Canada
South America
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Oceania
Australia
New Zealand
Cook Islands
Fiji
Kiribati
Marshall Islands
Nauru
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Other
Subcontractor for Exporter
_____________________
SBA Form 641 (10/24/2017)
3
Please note: The estimated burden for completing this form is 18 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 3
rd
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.
Asia Africa Caribbean Central America North America
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome