Small Business Development Centers of Ohio
at Kent State University Tuscarawas
E-Counseling Information Form
* are required fields, this form will not be submitted with out the needed information.
PART I: Client Request for Counseling
1a. Date: 5/16/2012 1b. History One Time   Initial
2a. Center Code: 2b. SBA District: 2c. Counselor Name:
3. Client Communication Type: Face to Face   Online   Telephone
4. Client Name (Name of the person completing the form/representative of the business)
*First Name:   Middle Initial:   *Last Name: 		5. Position/Title:
6. Business Name:
*7. Street Address/PO Box: (give business address if currently in business)
*8. City: *9. State: *10a. Zip: 10b. +4: 11. County:
*12. Email Address: *13. Business Phone:
14. Home Phone: 15. Business Fax: 16. Other Phone:
17. Website: 18. Business Description:
19. Client Preferences: No Mailings   No Public Release   No Email   SBA Impact Survey Release 20. Date of Birth:
PART II: Client/Owner Intake
21. Race
Asian
Black or African American
Native American or Alaska Native
Native Hawaiian or other Pacific Islander
White
No Response 		22. Ethnicity
Hispanic Origin
Not of Hispanic Origin
No Reply
 23. Gender
Male
Female
No Reply 		24. do you consider
yourself a person with a
disability?
Yes
No
No Reply
25a. Veteran Status
Non-Veteran   Veteran
Service-Connected Disabled Veteran   No Reply 		25b. Military Status
Member of Reserve or National Guard
On Active Duty
Not Military
26. What inspired you to contact us?
1st Stop Business Connection
Accountant/Attorney
Bank
Business Owner
Chamber of Commerce 		Education Institution
Government Agency
Internet
ITAC/ITD
Local ED Council 		Magazine
Newspaper
Other Client
PTAC
Radio/Television 		SBA
SBDC
Seminar
Word of Mouth
Other
*27. Business Status
Existing Declining
Existing Healthy
Pre-venture/Nascent
Start-up
No Response 		28. Business Start Date:
29. What is the legal entity of your business? (Business Organization)
C-Corporation
General Partnership
LLC
LLP 		Limited Partnership
Non Profit Corporation
Sole Partnership
S-Corporation
Foreign
Undecided
30. Type of Business (Choose primary category)
Accommodation & Food Services (72)
Administrative & Support (56)
Agriculture, Forestry, Fishing & Hunting (11)
Arts, Entertainment & Recreation (71)
Construction (23)
Finance & Insurance (52)
Educational Services (61)
Health Care & Social Assistance (62)
Information (51) 		Management of Companies & Enterprises (55)
Manufacturing - Food & Textiles (31)
Manufacturing - Non-Metal (32)
Manufacturing - Metals & Electronics (32)
Mining (21)
Other Services (except Public Administration) (81)
Parcel Delivery & Warehousing (49)
Professional, Scientific & Technical Services (54)
Public Administration (92) 		Real Estate & Rental & Leasing (53)
Retail Trade - Multiple Product Sales (45)
Retail Trade - Single Product Sales (44)
Transportation and Warehousing (48)
Utilities (22)
Wholesale Trade (05)
31. Business Ownership - What percentage of your business is male or female ownership?
%Male:

%Female:
32. NAICS:
33. Do you conduct business online?
Yes   No 		34. Is this a home based business?
Yes   No 		35. Is this a commercial based business?
Yes   No 		36. Is this a new product or technology?
Yes   No
37a. Do you export?
Yes   No
37b. Do you import?
Yes   No 		38. Is your business defense related?
Yes   No
39. What is the nature of the counseling you are seeking?
No Response
Access to Capital - Debt
Access to Capital - Equity
Agribusiness
Accounting/Budget/Inventory Setup
Business Planning
Business Start-up
Buy/Sell Business
Cash Flow Analysis & Management
Community Dev. Block Grant 		Commercialization
Computer Systems
Customer Relations
Engineering R&D
eVantage
Federal & State Tech. Program
Financial Analysis
Franchising
Government Contracting
Human Resources
 Intellectual Property
International Trade
International Trade Country Profiles
International Trade Market Research
Inventory Control
Legal Issues
Management/Leadership
Market Diversification
Market Planning
Operations Analysis & Planning
 Regulatory Compliance
Small Business Innovation Research
Strategic Planning
Tax Planning
Technology
Women’s Certification
Other
Describe specific assistance requested in the space provided.
40. Baseline Economic Indicators
40a. Full Time Employees: 40b. Part Time Employees: 40c. Gross Revenue/Sales
(for most recent full business year)
$ 		40d. +Profits/-Losses
(for most recent full business year)
-   +   $
41. I request business counseling service from the Small Business Administration (SBA) or an SBA Resource Partner. I agree to cooperate would 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 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. Please note: The estimated burden for completing this form is 3 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: US. 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.
42. Preferred date & time for appointment
Date:   Time: 		Date: 5/16/2012
*I accept that the above information is correct to the best of my knowledge.
Copyright © 2008 Ohio Small Business Development Center at Kent State University Tuscarawas. All rights reserved.

The Small Business Development Center Program of Ohio is a funded program of the Ohio Department of Development and the U.S. Small Business Administration in cooperation with Kent State University Tuscarawas. The support given through such funding does not constitute an express or implied endorsement of any of the co-sponsor(s) or participant(s) opinions, products or services. Special arrangements for the disabled will be made if requested in advance. This program is provided on a non-discriminatory basis.