Home ~ Counselor ~ Counseling Application
Name:
Phone Number's
Home :
Business :
Fax :
E-Mail :
Street Address :
City :
County :
State : Zip :
 
Race (mark one or more)
a. Native American or Alaskan Native d. Native Hawaiian or Pacific Islander
b. Asian e. White
c. Black/African American f.  Others
 
Ethnicity :
a.Hispanic Origin  
b.Not of Hispanic origin  
 
Business Owner Gender :
a.Male  
b.Female  
c.Male/Female  
 
Veteran Status :
a.Veteran c.Disabled Veteran
b.Service Connected Disabled d.Non-Veteran
   
 
How did you hear of us ? (mark one or more)
a. Word of mouth f.  Radio
b. Bank g. Television
c. Newspaper h. Magazine
d. Chamber of Commerce i.  SBA
e. Internet j. Others
 
Describe the nature of the counseling you are seeking :
 
Currently in Business ?
a. YES   
b. NO  
 
Is this a Home-based Business ?
a. YES  
b. NO  
 
Type of Business :
Name of Company :
How long in Business :
 
Indicate preferred date & time for appointment :  
Date : Time:
 

I request business management counseling from a Small Business Administrative Resource Partner. I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA assistance services. I authorize SBA to furnish relevant information to the assigned management counselor's. I understand that any information disclosed to be held in strict confidence by him/her.

I further understand that any counselor has agreed not to: (1) recommended goods or services from sources in which he/she has an interest and (2) accept fees or commission developing from this counseling relationship. In consideration of the counselor's) furnishing management or technical assistance, I waive all claims against personnel, SCORE and its host organization, and other SBA Resource Counselors arising from this assistance.

Please Note: The estimated burden for completing this form is 15 min. per person. You will not be required to respond to this information collection if a valid OMB approval number is not displayed. If you have question or comments concerning this estimate or other aspects of this information, please contact the U.S. Small Business Administration, Chief, Administrative Information Branch, Washington, DC 20416 and/or Office of Management and Budget, Clearance Officer, Paperwork Reduction Project(3245-0091), Washington, DC 20503.
Signature/Name : Date:
   
 
 

The OSBDC and SCORE work together in a team approach to give you a wealth of advice that will help make your business successful.  We are proud of what we do and are here to provide you with the best business counseling we can.  OSBDC is partially funded by the U.S. Small Business Administration.