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                            U.S. Small Business Administration            OMB Approval No. 3245-0324
                                                                Counseling Information Form                   Expiration Date: 09/30/2006
The purpose of this form is to collect information from clients and if eligible enroll them into the Veterans Business Outreach Program. Please fill out the information requested. When you have completed all questions be sure to submit the form.
PART I: Client Request for Counseling

1. Client Name (Name of the Person completing the form/representative of the business)

Last Name:
First Name:
Middle Initial:

2. Telephone(s):

Primary:
Secondary:
Fax:
3. Email Address:


                                          --If you don't have an e-mail address, please call 1-877-820-7492 (Toll Free) for assistance.--
4. Street Address:


5. City:


6. State:


7. Zip:


 9. I request business management 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 SBAproducts ans services. I understand that any information disclosed is to be held in strict confidence. (SBA will not provide your personal information to commercial entities.) I authorize SBA to furbish relevant information to the assigned management councelor(s). I further understand that any counselor has agreed 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 three 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,  D.C. 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.

10. Preferred date and time for appointment: (Only if in South Texas)

Date:(mm/dd/yyyy)
Time:(hh:mm AM/PM)

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

11. Race:
12. Ethnicity:
13. Gender:
14. Do you consider yourself a person with a disability?:
15. Veteran Status:
16. Military Status:
17. What inspired you to contact us?:
If other, please specify:
18. Currently in bussiness? (If no, skip to line 28):
19. Name of Company:
20. Type of bussiness:

















21. Business Ownership - What percentage of your business is male or female ownership?

% Male
% Female

22. Month & Year Business Started ? (mm/yyyy)
23. Do you conduct business online?
24. Is this a home based business?
25.Total No. of Employees: (full & part time)







26. For your most recent full business year, what were your:

Gross Revenues/Sales $
+Profits/-Losses $

27. What is the legal entity of your business?:
If other, please specify:




28. What is the nature of counceling you are seeking?

Chose primary category:
Describe specific assistance:

29. Indicate preferred date and time for Online Chat appointment:
      (Monday - Thursday)  (8:00am - 5:00pm)

Date:(mm/dd/yyyy)
Time:(hh:mm AM/PM)

30. Please choose a desired username and password:

User Name (No more than 20 characters):
Password (No more than 10 characters):