U.S. Small Business Administration OMB Approval No.

:3245-0324
Expiration Date: 10/31/2020
Counseling Information Form
Client Number:
Location Code:
Initials of Data Inputter:

1. Name of the Office Providing the Service _______________________________1a.

Ohio SBDC at Terra State Community College Type of Client: Face to Face Online Telephone
2. City/State of Office Location_________________________
Fremont, Ohio

PART I: Client Request for Counseling

3. Client Name (Name of the person completing the form/representative of the business) 4. Email
(Last, First, MI)
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
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.
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) 15. Ethnicity 16.Gender 17. Do you consider
American Indian or Alaska Native Hispanic or Latino Male yourself a person with
Asian Not Hispanic or Female a disability?
Black or African American Latino Yes No
Native Hawaiian or Other Pacific Islander
White
18. Veteran Status No military, Reserve, or Veteran Member of the Reserve Member of the National Guard
National Guard service Service-Disabled Veteran Active Duty Spouse of Military Member
19. Referred by? (Mark all that apply)
SBA District SBDC Other Client Magazine/Newspaper Other (specify)
Lender SCORE Educational Institution Word of Mouth USEAC
Business Owner WBC Local Economic Development Official Television/Radio Boots to Business
SBA Web site VBOC Chamber of Commerce Internet (please indicate website)

20a. Are you currently in business? Yes No (if no, skip to 30) 20b. If yes, are you currently exporting? Yes No
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).
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 24. Date Business 25. Do you conduct 26a. Are you a home based business Yes No
your business is male or female owned? Started?(MM/YYYY) business online? 26b. Are you 8(a) certified? Yes No
__________% Male__________% Female Yes No

27a. Total No. of Employees 28a. For your most recent full business year, what 29. What is the legal entity of your business?
(full & PT) were your: Gross Revenues/Sales $ Sole Proprietorship Corporation LLC
27b. Of total employees, how many are +Profits/-Losses $ S-Corporation Partnership
engaged in the exporting aspect of your 28b. Amount of your Gross Revenues/Sales Other (specify) ________________________________
business: (Full & PT) related to exporting $
30. What is the nature of counseling you are seeking? (Choose primary category)
Start-up Assistance (How do I start a Human Resources/ Marketing/Sales (promotion, market Technology/Computers
small business?) Managing Employees research, pricing, etc.) eCommerce (using the
Business Plan Customer Relations Government Contracting (including Internet to do business)
Financing/Capital (such as applying Business Accounting/ certifications) Legal Issues (such as,
for a loan, building equity capital) Budget Franchising Should I incorporate?)
Managing a Business Cash Flow Management Buy/Sell Business International Trade
Tax Planning
Describe specific assistance requested in the space provided. _____________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
SBA Form 641 (10/24/2017)
 U.S. Small Business Administration OMB Approval No.: 3245-0324
Counseling Information Form Expiration Date: 10/31/2020
Client Number:
Location Code:
Initials of Data Inputter:
Funding Source:

Part III: Counselor Record

31. Client Name (please use the same name from original 641 Part 1) 32. Email
(Last, First, MI)
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
39b. Is the client currently exporting? Yes No Started?
If yes, please turn to Appendix A on page 3 to indicate the markets to which your client currently exports (mark all that
apply).

41a. Total No. of Employees: (Full & PT) 42a. As of the most recent full business year, what were the client's annual:

41b. Of total employees, how many are engaged in Gross Revenues/Sales $_____________________ +Profits/-Losses $
the exporting aspect of client's business?:
42b. As of the most recent full business year, how much of your client's Gross
(Full & PT) Revenues/Sales were related to exporting? $

43. SBA or Resource Partner Service Contributed to the Following: (Mark all that apply)
SBA Loan Amount $ Certifications SBA Financial Assistance
8(a) Export Express
Non-SBA Loan Amount $ Hubzones
Export Working Capital Loan
Amount of Equity Capital Received $ SDB
Community Advantage
Other (specify state, local, etc) Micro loan
No. of Government Contracts/Subcontracts
SBIR
Annual Value of Government Contracts/Subcontracts Received
Other (SBIR, SBIC, 7(a) 504, etc)
$
44. What was the nature of the counseling you provided the client? (choose primary category)
Start-up Assistance (How do I start a Human Resources/Managing Marketing/Sales (promotion, Technology/Computers
small business?) Employees market research, pricing, etc.) eCommerce (using the Internet
Business Plan Customer Relations Government Contracting to do business)
Financing/Capital (such as, applying Business Accounting/Budget (including certifications) Legal Issues (such as, Should I
for a loan, building equity capital) Cash Flow Management Franchising incorporate?)
Managing a Business Tax Planning Buy/Sell Business International Trade
Please specify other counseling provided.
45. Referred Client to (mark all that apply):
WBC SBA District Office Export/Import Bank Dept of Commerce VBOC
SCORE USEAC OPIC Dept of State PTAC
SBDC State Trade Agency Dept of Agriculture U.S. Trade & Development Agency Other
46. Type of Session 47. Language(s) Used 48. History 49. Date Counseled
Face to Face Online Update English Other (specify) New Case Follow-up (MM/YYYY)
Telephone Prep Spanish
One Time
50. Counselor(s) Name (If multiple counselors, list lead counselor first and separate 51. Contact Hours 51b. Prep Hours
each additional counselor name by a semi-colon): Total contact hours Total amount of
that a client received preparation spent by all
counselors for a client

51c.Travel Hours Total amount of time it takes to travel to a client's location for counseling
52 Did more than one Counselor participate in this counseling session? Yes__ No__. If yes, how many counselors ________?
53. Counselor’s Notes:

SBA Form 641 (10/24/2017) 2

 U.S. Small Business Administration OMB Approval No.:3245-0324
Expiration Date: 10/31/2020
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)

Asia Africa Caribbean Central America North America

Afghanistan Algeria Anguilla Belize Bermuda

Bahrain Angola Antigua & Barbuda Costa Rica Mexico
Bangladesh Benin Aruba El Salvador Canada
Belarus Botswana Bahamas Guatemala
Bhutan Burkina Faso Barbados Honduras
Burundi Virgin Islands (British)
Brunei
Cameroon
Nicaragua South America
Burma Cayman Islands
Panama
Cambodia Cape Verde Cuba
China Central African Republic Dominica Argentina
East Timor Chad Dominican Republic Europe Bolivia
Georgia Comoros Grenada Austria Brazil
Hong Kong Congo Haiti Azerbaijan Chile
India Democratic Republic of Congo Jamaica Albania Colombia
Indonesia Cote d'Ivoire Montserrat Armenia Ecuador
Iran Djibouti Netherlands Antilles Belgium Guyana
Iraq Egypt St. Kitts and Nevis Bosnia-Herzegovina Paraguay
Israel Equatorial Guinea St. Lucia Bulgaria Peru
Japan Eritrea St. Vincent and Grenadines Croatia Suriname
Jordan Ethiopia Trinidad and Tobago Cyprus Uruguay
Kazakhstan Gabon Czech Republic Venezuela
Korea, North Gambia Denmark Oceania
Korea, South Ghana Estonia Australia
Kuwait Guinea Finland New Zealand
Kyrgyzstan Guinea-Bissau France Cook Islands
Laos Kenya Germany Fiji
Lebanon Lesotho Greece Kiribati
Macau Liberia Hungary Marshall Islands
Malaysia Libya Iceland Nauru
Maldives Madagascar Ireland Palau
Micronesia Malawi Italy Papua New Guinea
Mongolia Mali Latvia Samoa
Nepal Mauritania Liechtenstein Solomon Islands
Oman Mauritius Lithuania Tonga
Pakistan Morocco Luxembourg Tuvalu
Philippines Mozambique Macedonia Vanuatu
Qatar Namibia Malta
Russia Niger Moldova
Nigeria Monaco
Saudi Arabia
Montenegro Other
Singapore Rwanda
Sri Lanka Sao Tome and Principe Netherlands
Norway Subcontractor for Exporter
Syria Senegal
Tajikistan Seychelles Poland _____________________
Taiwan Sierra Leone Portugal
Thailand Somalia Romania
Turkey South Africa Serbia
Turkmenistan Sudan Slovak Republic
United Arab Emirates Swaziland Slovenia
Uzbekistan Tanzania Spain
Vietnam Togo Sweden
Yemen Tunisia Switzerland
Uganda Turkey
Zambia Ukraine
Zimbabwe United Kingdom
Vatican City
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 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.

SBA Form 641 (10/24/2017) 3