Form SBA FORM SBA FORM Counseling Information Form

Entrepreneurial Development Management Information System (EDMIS) Counseling Information Form & Management Training Report

SBA Form 641 Aug. 3 .11

Entrepreneurial Development Management Information System (EDMIS) Counseling Information Form & Management Training Report

OMB: 3245-0324

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U.S. Small Business Administration

Counseling Information Form

OMB Approval No.:3245-0324

Expiration Date: 07/31/2011

Client Number:

Location Code:

Initials of Data Inputter:


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 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 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

Italy

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

Federated States of Micronesia

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 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.

SBA Form 641 (07/31/2011)

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