Form SBA FORM 641 SBA FORM 641 COUNSELING INFORMATION FORM

U.S. Small Business Administration Counseling Information Form	OMB Approval No.: 3245-0324 Expiration Date: 11/30/2013
	Client Number: Location Code: Initials of Data Inputer:

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

2. City/State of Office Location_________________________

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 Native Hawaiian or Other Pacific Islander Asian White Black or African American

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. Referred by? (Mark all that apply) SBA District Office SBDC Other Client Magazine/Newspaper Other (specify) _____________ Lender USEAC Educational Institution Word of Mouth Business Owner SCORE Local Economic Development Official Television/Radio SBA Web site WBC Chamber of Commerce Internet (please indicate website)_____________________

20a. Are you currently in business? Yes No (if no, skip to 30) 20b. If yes, are you currently exporting? Yes No If yes to 20b, please go to Appendix A on page 3 to indicate the markets to which your company currently exports (mark all that apply).

21. Name of Business

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 owned? __________% Male__________% Female

24. Date Business Started?(MM/YYYY)

25. Do you conduct business online? Yes No

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

27a. Total No. of Employees (Full & PT)________ 27b. Of total employees, how many are engaged in the exporting aspect of your business? (Full & PT)_____

28a. For your most recent full business year, what were your: Gross Revenues/Sales $_____________ +Profits/-Losses $___________________ 28b. Amount of your Gross Revenues/Sales related to exporting $_________________

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______________________________________________________________________________

Funding Source

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

39a. Is the client currently in business? Yes No (If no, skip to 44) 39b. Is the client currently exporting? Yes No If yes, please turn to Appendix A on page 3 to indicate the markets to which your client currently exports (mark all that apply).

40. Date Business Started? (MM/YYYY)

41a. Total No. of Employees: (Full & PT)_____ 41b. Of total employees, how many are engaged in the exporting aspect of client’s business?: (Full & PT)_____

42a. As of the most recent full business year, what were the client’s annual: Gross Revenues/Sales $____________+Profits/-Losses$______________ 42b. As of the most recent full business year, how much of your client’s Gross Revenues/Sales were related to exporting? $______________

43. SBA or Resource Partner Service Contributed to the Following: (Mark all that apply)

SBA Loan Amount $____________________ Non-SBA Loan Amount $ ________________ Amount of Equity Capital Received $__________ No. of Government Contracts/Subcontracts________ Annual Value of Government Contracts/Subcontracts Received $ ________

Certifications 8(a) HUBZone Women Owned Small Business Other (specify state, local, etc) _______________________________

SBA Financial Assistance Export Express Export Working Capital Loan Community Advantage Micro loan SBIR Other ( SBIC, 7(a) 504, 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. Referred Client to (mark all that apply): WBC SBA District Office Export/Import Bank Dept of Commerce Other_________________ SCORE USEAC OPIC Dept of State SBDC State Trade Agency Dept of Agriculture U.S. Trade & Development Agency

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

47. Language(s) Used: English Other (specify)____________ Spanish

48. History New Case Follow-up One Time

49. Date Counseled (MM/YYYY)

50. Counselor(s) Name (If multiple counselors, list lead counselor first and separate each additional counselor name by a semi-colon):

51. Contact Hours Total contact hours that a client received______

51b. Prep Hours Total amount of preparation spent by all of the counselors for a client_____

51c. Travel Hours Total amount of time it takes to travel to a client’s location for counseling ______

52. Did more than one counselor participate in this counseling session? Yes__ No__ If yes, how many counselors? ________

53. Counselor’s Notes:

Appendix A to Questions 20b. & 39b.

If your company is currently exporting, please indicate the countries to which your company exports: (Mark all that apply)

Asia	Africa	Caribbean	Central America	North America
Afghanistan Bahrain Bangladesh Belarus Bhutan Brunei Burma Cambodia China East Timor Georgia Hong Kong India Indonesia Iran Iraq Israel Japan Jordan Kazakhstan Korea, North Korea, South Kuwait Kyrgyzstan Laos Lebanon Macau Malaysia Maldives Micronesia Mongolia Nepal Oman Pakistan Philippines Qatar Russia Saudi Arabia Singapore Sri Lanka Syria Tajikistan Taiwan Thailand Turkey Turkmenistan United Arab Emirates Uzbekistan Vietnam Yemen	Algeria Angola Benin Botswana Burkina Faso Burundi Cameroon Cape Verde Central African Republic Chad Comoros Congo Democratic Republic of Congo Cote d’Ivoire Djibouti Egypt Equatorial Guinea Eritrea Ethiopia Gabon Gambia Ghana Guinea Guinea-Bissau Kenya Lesotho Liberia Libya Madagascar Malawi Mali Mauritania Mauritius Morocco Mozambique Namibia Niger Nigeria Rwanda Sao Tome and Principe Senegal Seychelles Sierra Leone Somalia South Africa Sudan Swaziland Tanzania Togo Tunisia Uganda Zambia Zimbabwe	Anguilla Antigua & Barbuda Aruba Bahamas Barbados Virgin Islands (British) Cayman Islands Cuba Dominica Dominican Republic Grenada Haiti Jamaica Montserrat Netherlands Antilles St. Kitts and Nevis St. Lucia St. Vincent and Grenadines Trinidad and Tobago	Belize Costa Rica El Salvador Guatemala Honduras Nicaragua Panama	Bermuda Mexico Canada
			Europe	South America
			Austria Azerbaijan Albania Armenia Belgium Bosnia-Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Finland France Germany Greece Hungary Iceland Ireland Latvia Liechtenstein Lithuania Luxembourg Macedonia Malta Moldova Monaco Montenegro Netherlands Norway Poland Portugal Romania Serbia Slovak Republic Slovenia Spain Sweden Switzerland Turkey Ukraine United Kingdom Vatican City	Argentina Bolivia Brazil Chile Colombia Ecuador Guyana Paraguay Peru Suriname Uruguay Venezuela
				Oceania
				Australia New Zealand Cook Islands Fiji Kiribati Marshall Islands Nauru Palau Papua New Guinea Samoa Solomon Islands Tonga Tuvalu Vanuatu
				Other
				Subcontractor for Exporter Sell to fill-freight

Please note: The estimated burden for completing this form is 23 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 (1/2011)