SCORE-Erie Request for Counseling

Request Form

Date

Email:

Name:

Street Address:

City:

State: Zip Code:

Website:

Owner's Gender:

Home Phone:

Work Phone:

Cell Phone:

Fax:

I request business counseling service from the Small Business Administration 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.

Indicate preferred date & time for appointment:

Do you consider yourself a person with a disability? Yes No

Race

Ethnicity:

Veteran Status:

Military Status:

What prompted you to contact us: (mark all that apply)
Website SBA Bank Television/Radio Magazine Billboard Newspaper Business Owner Other Client Chamber of Commerce Educational Institution Local Economic Development Official Word of Mouth Other

Are you currently in business Yes No Name of Company

Type of business: (choose primary category)			Other Services (Not Public Admin)
Mining	Manufacturing	Real Estate/Rental/Lease	Professional/Scientific/ Technical Services
Utilities	Finance/ Insurance	Health Care/ Social Assistance	Management of Companies & Enterprises
Information	Wholesale Trade	Accommodations/ Food Services	Agriculture, Forestry, Fishing & Hunting
Construction	Public Administration	Arts, Entertainment, Recreation	Administrative Support
Retail Trade	Educational Services	Transportation/Warehousing	Waste Management/Remediation Services

Business Ownership - What % of your business is male or female ownership? MaleFemale	Month & Year Business Started?	Do you conduct business online? Yes No	Is this a home-based business? Yes No
Legal Entity: Sole Proprietorship Partnership Corporation S-Corporation LLC Other
Type of Counseling : Face to Face Telephone Online

What is the nature of counseling you are seeking? (Choose primary category)
Start-Up Assistance (How do I start a small business?)	Human Resources/ Managing Employees	Marketing/Sales	Technology/Computers
Business Plan	Customer Relations	Government Contracting	eCommerce
Financing/Capital	Business Accounting/Budget	Franchising	Legal Issues (such as should I incorporate?)
Managing a business	Cash Flow Management Tax Planning	Buy/Sell Business	International Trade

Describe specific assistance requested in the space provided:

SBA Form 641 (7/07) Previous Editions Obsolete