Client Information

Last Name *

First Name *

Email Address

Telephone Number

Primary *



Street Address/P. O. Box

Street Address 1 *

Street Address 2

City *


Zip *

Zip +4

Disclaimer *

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 to use my name and address for SBA surveys and information mailing regarding SBA products and services.

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 entrepreneurial development programs and grants, and to meet Congressional and Executive Branch reporting requirements. The form should be submitted at the site of services to the counselor providing the service. Resource Partners will submit information to SBA according to the terms of their notice of award.

Preferred date & time for appointment



Part II:Client Intake (to be completed by all clients)

Race *

Black or African AmericanAmerican Indian or Alaska NativeAsianWhiteNative Hawaiian or Other Pacific Islander

Ethnicity *

Not Hispanic or LatinoHispanic or Latino

Gender *


Do You Consider Yourself a Person With a Disability? *


Veteran Status *

Non-VeteranService Disabled VeteranVeteran

Military Status

Member of Reserve or National GuardOn Active Duty

What inspired you to contact us? * (Mark All That Apply)

SBABankBusiness OwnerTelevision/RadioOther ClientMagazine & NewspaperInternetChamber of CommerceEducational InstitutionLocal Economic Development OfficialWord of MouthSBA WebsiteSBDCUSEACSCOREWBCOther (Specify)

Other (specify)

Internet (specify)

Are You Currently in Business? *


If yes, are you currently exporting?


If Your Company is Currently Exporting, Please Indicate the Countries to Which Your Company Exports (Mark all that apply)


AfghanistanBangladeshBelarusBhutanBruneiCambodiaChinaGeorgiaHong kongIndiaIndonesiaJapanKazakhstanKorea, NorthKorea, SouthKyrgyzstanLaosMacaoMalaysiaMaldivesMicronesiaMongoliaNepalPakistanPhilippinesRussiaSingaporeSri LankaTaiwanThailandUzbekistanVietnam


AlgeriaAngolaBeninBotswanaBurkina FasoBurundiCameroonCape VerdeCentral African RepublicChadComorosCongoThe Democratic Republic Of CongoCote D'ivoireDjiboutiEgyptEquatorial GuineaEritreaEthiopiaGabonGambiaGhanaGuineaGuinea-BissauKenyaLesothoLiberiaLibyaMadagascarMalawiMaliMauritaniaMauritiusMoroccoMozambiqueNamibiaNigerNigeriaRwandaSao Tome And PrincipeSenegalSeychellesSierra LeoneSomaliaSouth AfricaSudanSwazilandTanzaniaTogoTunisiaUgandaZambiaZimbabwe


AnguillaAntigua And BarbudaAGArubaBahamasBarbadosBritish Virgin IslandsCayman IslandsCubaDominicaDominican RepublicGrenadaHaitiJamaicaMontserratSaint Kitts And NevisSaint LuciaSaint Vincent And The GrenadinesTrinidad And Tobago

Central America

BelizeCosta RicaEl SalvadorGuatemalaHondurasNicaraguaPanama


AustriaAlbaniaArmeniaAzerbaijanBosnia And HerzegovinaBulgariaCroatiaCyprusCzech RepublicDenmarkEstoniaFinlandFranceGermanyGreeceHungaryIcelandIrelandItalyLatviaLiechtensteinLithuaniaLuxembourgMacedoniaMaltaMoldovaMonacoMontenegroNetherlandsNorwayPolandPortugalRomaniaSerbiaSlovakiaSloveniaSpainSwedenSwitzerlandTurkeyUkraineUnited KingdomVatican City State

North America


South America

ArgentinaBoliviaBrazilChileColombiaEcuadorFRENCH GUIANAGuyanaPeruSurinameUruguayVenezuela


AustraliaCook IslandsFijiKiribatiMarshall IslandsNauruPalauPapua New GuineaSamoaSoloman IslandsTongaTuvaluVanuatuNew Zealand


Sell to fill-freightSubcontractor for Exporter

Name of Company

Type of Business

Agriculture, Forestry, Fishing and HuntingMiningUtilitiesConstructionManufacturingWholesale TradeRetail TradeTransportation and WarehousingInformationFinance and InsuranceReal Estate and Rental and LeasingProfessional, Scientific, and Technical ServicesManagement of Companies and EnterprisesAdministrative and SupportWaste Management and Remediation ServicesEducational ServicesHealth Care and Social AssistanceArts, Entertainment, and RecreationAccommodation and Food ServicesOther Services (except Public Administration)Public Administration

Male Ownership Percentage

Female Ownership Percentage

Month & Year Business Started



Do you conduct business online?


Is this a home based business?


Are you 8(a) certified?


Total number of Employees (Full & Part Time)

Of total employees, how many are engaged in the exporting aspect of you business? (Full & PT)

Your Gross Revenues/Sales

+ Profits / - Losses

Amount of your Gross Revenue/Sales related to exporting

What is the legal entity of your business?

Sole Proprietorship
Limited Liability Company(LLC)
S Corporation
Other Legal entity

Other Legal entity

What is the nature of counseling you are seeking? *
Start-up AssistanceBusiness PlanFinancing/CapitalManaging BusinessHuman Resources/Managing EmployeesCustomer RelationsBusiness Accounting/BudgetCash Flow ManagementTax PlanningMarketing/SalesGovernment ContractingFranchisingBuy/Sell a BusinessTechnology/ComputerseCommerceLegal IssuesInternational TradeOther

Describe Specific Assistance