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    Request For Assistance

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    alexsbdc
    This document contains a counseling information form for a small business development center. It collects information such as the client's name and contact details, business name if already in business, address, demographic information, type of business, number of employees, revenues, inspiration for contacting the center, and a signature agreeing to terms including keeping the counseling information confidential and not accepting fees from referred sources. The client requests business counseling from the Small Business Administration or partner and agrees to participate in surveys about the services.

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    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    Request For Assistance

    Uploaded by

    alexsbdc
    24 views2 pages
    This document contains a counseling information form for a small business development center. It collects information such as the client's name and contact details, business name if already in business, address, demographic information, type of business, number of employees, revenues, inspiration for contacting the center, and a signature agreeing to terms including keeping the counseling information confidential and not accepting fees from referred sources. The client requests business counseling from the Small Business Administration or partner and agrees to participate in surveys about the services.

    Original Description:

    Alexandria, Virginia, Small Business Development Center Request for Assistance.

    Original Title

    Request for Assistance

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    This document contains a counseling information form for a small business development center. It collects information such as the client's name and contact details, business name if already in business, address, demographic information, type of business, number of employees, revenues, inspiration for contacting the center, and a signature agreeing to terms including keeping the counseling information confidential and not accepting fees from referred sources. The client requests business counseling from the Small Business Administration or partner and agrees to participate in surveys about the services.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    24 views2 pages

    Request For Assistance

    Uploaded by

    alexsbdc
    This document contains a counseling information form for a small business development center. It collects information such as the client's name and contact details, business name if already in business, address, demographic information, type of business, number of employees, revenues, inspiration for contacting the center, and a signature agreeing to terms including keeping the counseling information confidential and not accepting fees from referred sources. The client requests business counseling from the Small Business Administration or partner and agrees to participate in surveys about the services.

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    Alexandria Small Business

    Development Center Client Number:


    (For internal use only.)
    Counseling Information Form

    Client Request for Counseling


    Client Name (Name of the person completing this form/representative of the business) Email
    (First Last)

    Position/Title (if already in business) Day Telephone

    Business Name (if already in business) Night Telephone

    Street Address/PO Box (give business address if currently in business) Fax

    City State Zip Business Description

    Race (mark one or more) Ethnicity Gender Veteran Status


    Asian Hispanic Male Non-Veteran Veteran Service-Disabled Veteran
    Black or African American Origin Female
    Native American or Alaska Native Not of Do you consider Military Status
    Native Hawaiian or other Pacific Islander Hispanic yourself a person Member of Reserve or National Guard
    White Origin with a disability? On Active Duty
    Yes No

    Are you currently in business? Month & Year Business Started? What is the legal entity of your business?
    Yes Sole Proprietorship Corporation LLC
    No (if no, skip to next section) S-Corporation Partnership
    Other (specify) ________________________________
    Type of Business (choose best 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)
    What percentage of your business is female owned? ________% Number of Employees For your most recent full business year:
    Do you conduct business online? Yes Full Time: Gross Revenues / Sales $______________
    Is this a home based business? Yes Part Time: +Profits / -Losses $______________

    Describe specific assistance requested : _______________________________________________________________________________________________________


    _______________________________________________________________________________________________________________________________________
    _______________________________________________________________________________________________________________________________________

    What inspired you to contact us? (mark best choice)


    SBA Other Client Chamber of Commerce Other (specify) _______________________________
    Bank Magazine Educational Institution
    Business Owner Internet Local Economic Development Official
    . Television/Radio Newspaper Word of Mouth
    Client Signature Date:

    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.

    SBA Form 641 (5/04) Previous Editions are Obsolete


    FAX completed form to 703-778-1293 OR MAIL to Alexandria SBDC, 801 N. Fairfax St., #402, Alexandria, VA 22314

    Jan. 2007
    To comply with legislation passed by the Congress and Executive Orders issued by the President, Federal executive agencies, including the Small
    Business Administration (SBA) must notify you of certain information. You can find the regulations and policies implementing these laws and
    Executive Orders in Title 13, Code of Federal Regulations (CFR), Chapter 1, or our Standard Operating Procedures (SOPs). In order to provide the
    required notices, the following is a brief summary of the various laws and Executive Orders that affect SBA’s entrepreneurial development programs.

    Paperwork Reduction Act (44 U.S.C. § 3501)

    SBA is collecting the information on this form in order to facilitate business assistance services to its clients and for agency analyses related to the
    operation and management of entrepreneurial development programs. Periodically, the SBA may use the information collected on this form to produce
    summary reports for program and management analysis as required by law. SBA also intends to use the individual client data to select participants for
    follow-up surveys designed to evaluate SBA assistance services.

    PLEASE NOTE: The estimated burden for completing this information is 3 minutes. Your responses to the requested information are voluntary
    under these programs. You are not required to respond to the questions on this form if it does not display a currently valid OMB control number. If
    you have questions or comments concerning any aspect of this information, please contact the U.S. Small Business Administration Branch,
    Washington, DC, 20416 and/or Desk Officer for the Small Business Administration, Office of Management and Budget, Office of Information
    Regulatory Affairs, 725 17th Street, NW, Washington, DC 20503.

    Privacy Act (5 U.S.C. § 552)


    Note: Any person concerned with the collection, use, and disclosure of information, under the Privacy Act may contact the Chief, Freedom of
    Information/Privacy Act office, U.S. Small Business Administration, Suite 5900, 409 3rd St., SW, Washington, DC 20416 for information about the
    Agency’s procedures relating to the Privacy Act and FOIA.
    Freedom of Information Act (5 U.S.C § 552)
    This law provides, with some exceptions, that SBA must supply information in its files and records to a person requesting it. This generally includes
    statistical data on SBA’s business assistance programs, which are in the aggregate. SBA does not routinely make available a client’s proprietary data
    (without first doing pre-notification, as required by Executive Order 12600), or information that would cause competitive harm or constitute a clearly
    unwarranted invasion of personal privacy.
    Address a request under this Act to the appropriate SBA office and identify it as a Freedom of Information Act request. For information about the
    Freedom of Information Act, contact Chief, Freedom of Information/Privacy Act Office, U.S. Small Business Administration, 409 3rd St., SW, Suite
    5900, Washington, DC 20416.

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