Part
I: Client Request for Counseling
*
Client Name:
*
Email:
*
Phone:
Fax:
*
Address:
*
City:
*
State:
*
Zip:
I request counseling services 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 will permit SBA
or its agent the use of my name and address for SBA surveys
and information mailings regarding SBA products and services
(Yes
Part
II: Client Intake
Race: (mark one or more)
[ Select one or more ]
None selected
Asian
Black or African
American
Native
American or Alaskan Native
Native
Hawaiian or Pacific Islander
White
Ethnicity:
[Select one ]
None selected
Hispanic Origin
Not of Hispanic Origin
Gender:
[ Select one ]
None selected
Male
Female
Do you
consider yourself a person with a diability?
[ Select one ]
None Selected
Yes
No
Military Status:
[ Select one ]
None selected
Not Applicable
Member of Guard
or Reserves
On Active Duty
Veteran
Status:
[ Select one ]
None selected
Non-Veteran
Veteran
Service-Disabled
Veteran
What inspired you to contact
us? (choose all that apply)
[ Select one or more ]
None selected
SBA
Bank
Business Owner
Television/Radio
Other Client
Magazine
Internet
Newspaper
Chamber of Commerce
Educational Institution
Local
Economic Development Office
Word of Mouth
Other
Is the
client currently in business?
[ Select one ]
Yes
No
Name of Company
Type
of company (choose primary category)
[ Select one ]
N/A
Mining
Utilities
Information
Construction
Retail Trade
Manufacturing
Finance and Insurance
Wholesale Trade
Public Administration
Educational Services
Real
Estate and Rental and Leasing
Health
Care and Social Assistance
Accomodations
and Food Services
Arts,
Entertainment and Recreation
Transportation
and Warehousing
Professional,
Scientific and Technical Services
Management
of Companies and Enterprises
Agriculture,
Forestry, Fishing and Hunting
Administrative
and Support
Waste
Management and Remediation Services
Other
Services (except Public Admin)
Business Ownership (What
percentage of your business is male or female? Please
enter numbers only)
Male:
Female:
Month and
Year your business started
[ Select one ]
N/A
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
[ Select one ]
N/A
Do you
conduct business online?
[ Select one ]
None selected
N/A
Yes
No
Is this a home based business?
[ Select one ]
None selected
N/A
Yes
No
Total No.
of Employees (full and part time)
What is the legal entity
of your business?
[ Select one ]
None selected
N/A
Sole Proprietorship
S-Corporation
Corporation
Partnership
LLC
Other
For your most recent
business year, what were your:
Revenues/Sales
$
+Profits/ -Losses
$
What is the nature of counseling you are seeking?
(Choose primary category)?
[ Select One ]
None selected
Start-Up Assistance
Business Plan
Financing/Capital
Managing a Business
Human Resources
Customer Relations
Business Accounting/Budget
Cash Flow Management
Tax Planning
Marketing/Sales
Government Contracting
Franchising
Buy/Sell Business
Technology
eCommerce
Legal Issues
International Trade
Describe specific assistance
requested:
*User Name
*Password
* Used to log in to view
and download documents from our site.
"The
Alabama International Trade Center is an Institutional Member of the
Alabama Small Business Development Consortium.