Sba Form 641 Counseling Information Form

	U.S. Small Business Administration Counseling Information Form	OMB Approval No. 3245-324 Expiration Date: Case Number: Locator Number: Initials of Data Inputer:
Resource Name: ________________________________________ Location: (City/State) ___________________________________

1. Name of the Office Providing the Service _______________________________1a. Type of Client: Face to Face Online

2. City/State of Office Location_________________________ Telephone

PART I: Client Request for Counseling

3. Client Name (Name of the person completing the form/representative of the business) (Last, First, MI)		4. Email
5. Telephone 6. Fax Primary Secondary
7. Street Address/PO Box (give business address if currently in business) 8. City 9. State 10. Zip				+4
11. 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 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. Please note: The estimated burden for completing this form is 18 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: U.S. 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.
12. Preferred date & time for appointment Date: Time:	13. Client Signature		Date:

PART II: Client Intake (to be completed by all Clients)

14. Race (mark one or more) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White

15. Ethnicity Hispanic or Latino Not Hispanic or Latino

16.Gender Male Female

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

18. Veteran Status Non-Veteran Veteran Service-Disabled Veteran

18a. Military Status Member of Reserve or National Guard On Active Duty

19. What prompted you to contact us? (mark all that apply) SBA District SBA Web site Other Client Chamber of Commerce Lender Magazine Educational Institution Business Owner Internet Local Economic Development Official . Television/Radio Newspaper Word of Mouth Other (specify) ______________________________

20. Are you currently in business? Yes No (if no, skip to 30)

21. Name of Company

22. Type of Business (choose primary category) Professional, Scientific & Technical Services Mining Manufacturing Real Estate & Rental & Leasing Management of Companies & Enterprises Utilities Finance & Insurance Health Care & Social Assistance Agriculture, Forestry, Fishing & Hunting Information Wholesale Trade Accommodation & Food Services Administrative & Support Construction Public Administration Arts, Entertainment & Recreation Waste Management & Remediation Services Retail Trade Educational Services Transportation & Warehousing Other Services (except Public Administration)

23. Business Ownership – What percentage of your business is male or female ownership? __________% Male__________% Female

24. Month & Year Business Started?

25. Do you conduct business online? Yes No

26 Are you a 26a. Are you 8(a) home based certified? Business? based business? Yes No Yes No

27. Total No. of Employees (full & part time)

28. For your most recent full business year, what were your: Gross Revenues/Sales $______________ +Profits/-Losses $___________________

29. What is the legal entity of your business? Sole Proprietorship Corporation LLC S-Corporation Partnership Other (specify) ________________________________

30. What is the nature of counseling you are seeking? (Choose primary category)

Start-up Assistance (How do I start a small business?) Business Plan Financing/Capital (such as applying for a loan, building equity capital) Managing a Business

Human Resources/ Managing Employees Customer Relations Business Accounting/ Budget Cash Flow Management Tax Planning

Marketing/Sales (promotion, market research, pricing, etc.) Government Contracting (including certifications) Franchising Buy/Sell Business

Technology/Computers eCommerce (using the Internet to do business) Legal Issues (such as, Should I incorporate?) International Trade

Describe specific assistance requested in the space provided. ___________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Part III: Counselor Record

31. Client Name (please use the same name from original 641 Part 1) (Last, First, MI)

32. Email

33. Telephone 34. Fax Primary Secondary

35. Street Address /P.O. Box 36. City 37. State 38. Zip

+4

39. Is the client currently in business? Yes No (if no, skip to 44)

40. Month & Year Business Started?

41. Total No. of Employees (full & PT)

42. As of the most recent counseling date and for the most recent business year, what are the client’s annual: Gross Revenues/Sales $_____________________ +Profits/-Losses$__________________________

43. SBA or Resource Partner Service Contributed to the Following: Certifications SBA Financial Assistance $_______________ SBA Loan Amount 8(a) Community Express Hubzones Micro loan $_______________ Non-SBA Loan Amount SDB Other (SBIR, SBIC, 7(a) 504, etc)__________________ $_______________ Amount of Equity Capital Received Other (specify state, local, etc) ______________________________

44. What was the nature of the counseling you provided the client? (choose primary category)

Start-up Assistance (How do I start a small business?) Business Plan Financing/Capital (such as, applying for a loan, building equity capital) Managing a Business

Human Resources/Managing Employees Customer Relations Business Accounting/Budget Cash Flow Management Tax Planning

Marketing/Sales (promotion, market research, pricing, etc.) Government Contracting (including certifications) Franchising Buy/Sell Business

Technology/Computers eCommerce (using the Internet to do business) Legal Issues (such as, Should I incorporate?) International Trade

Please specify other counseling provided. ___ __________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

45. Type of Session Face to Face Online Update Telephone Prep

46. Language(s) Used English Spanish Other (Specify)_____________________________

47. History New Case Follow-up One Time

48. Date Counseled

49. Counselor(s) Name

50a. Contact Hours

50b. Prep Hours

50c. Travel Hours

51– Did more than one Counselor participate in this counseling session? Yes__ No__. If yes, how many counselors ________? Please list the lead counselor first in item 49 and the actual client hours (time the client spent in this session, not the “billable” counselor time) provided for contact, prep and travel.

52. Counselor’s Notes:

Please note: The estimated burden for completing this form is 18 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: U.S. Small Business Administration, 409 3^rd 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.

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SBA Form 641 (6/03)