form

Request for Counseling Form

A. Contact information: (Required)

First Name:
Last Name:
Address:
City:
State/Province:
Zip:
Website Address:
Email Address:

Phone Numbers:	ex: (315) 555-5555
Home:
Business:
Fax:
Cellular:
Beeper:

B. Demographic information: (Optional)

How did you hear about us?:

Race:

Ethnicity:	Hispanic Origin Not of Hispanic Origin:

Business Owner Gender:	Male Female Male/Female Part. Male/Male Part. Female/Female Part.

Veteran Status:	Veteran: Vietnam Era Veteran: Gulf War Veteran: Non-Veteran:

Are you disabled?:	yes no

C. Business information: (Required)

Currently in Business?:	yes no (If no, skip to section D)
Name of Business:
State in which business operates:
Describe your business:
How long in business?:	Years

Business Status:	Start up Buyout - venture proceeded Existing Bus. Vent. Term In business 1 year In business 1 - 3 years In business 3 - 5 years In business 5 years

Business Form:	Sole proprietorship Partnership Corporation

SBA Client (Past or Present):	Borrower Applicant 8 (a) Client Surety Bond COC 8 (a) + Borrower 8 (a) + Surety Bond SBIR SBIC None

Exporter:	Export only Import only Both export and import Interested in either export or import None


Is this a home based business?:	yes no


Describe the nature of the counseling you are seeking:

Best time for contact:

D. If you are a Start Up Business

We recommend that you attend a Business Start Up Class before you come in for one to one counseling. Once you complete and submit this form, you will be contacted for class options.

E. New York State Small Business Development Center Client Disclaimer (Required)

I request management assistance from The New York State Small Business Development Center. I understand that this assistance is free of charge and that I incur no obligation to The New York State SBDC or the U.S. Small Business Administration or its counselors for providing this assistance. I agree to cooperate should I be selected to participate in surveys designed to evaluate assistance services. I authorize the NYS/SBDC to furnish relevant information to the assigned management counselor(s) although I expect that information to be held in strict confidence to the extent allowable by law.

I further understand that any counselor has agreed not to: (1) recommend goods or services from sources in which he/she has a interest and (2) accept fees or commissions developing from this counseling relationship. In consideration of the SBDC, in cooperation with the SBA furnishing management or technical assistance, I waive all claims against The New York State SBDC, SBA, personnel or counselors arising from this assistance.