Blue (*) fields are required.
*Type Of Counseling: Face-to-Face Counseling   Telephone Counseling   Online  
Entering Parts 1 and 2 only
*Last Name: - ERROR
 *First Name: - ERROR
 Middle Initial:
*Email Address: - ERROR
 
 Primary Phone: - ERROR
- - 		Secondary Phone: - ERROR
- - 		Fax: - ERROR
- -
 Street Address: - ERROR
  City: - ERROR
 State: - ERROR
 *Zip: - ERROR
*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.
 What is the nature of counseling you are seeking? - ERROR



 Please describe your business and the specific assistance requested. - ERROR
*Race:
 *Ethnicity:
 *Gender:
*Do you consider yourself
a person with a disability?
Yes   No		 *Veteran Status:
 *Military Status:
*What prompted you to contact us? (Check all that apply) - ERROR
SBA District Other Client Chamber of Commerce Other     
Lender Magazine Educational Institution SBA Website
Business Owner Internet Local Economic Development Official
Television/Radio Newspapers Word Of Mouth Choose Not to Respond
*Currently In Business (If yes, all blue (*) fields are required.)
Yes
No 		 Company Name - ERROR
 Type of Business - ERROR

  Business Ownership
 Male
 Female
 Month & Year Business Started
- ERROR
Month:
Year: (format YYYY) 		 Do you conduct business online?
Yes No		  Are you a home based business?
Yes No
 Total No. of Employees - ERROR
(full & part-time)
For your most recent full business year, what were your:
- Error
Gross Revenues/Sales $
+Profits/-Losses $ 		 Are you 8(a) certified?
Yes No

Learn More about 8(a)
 What is the legal entity of your business?

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