Sba Form 641 - Counseling Information Form
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2OMB Approval No.:3245-0324
U.S. Small Business Administration
Expiration Date: 09/30/2014
Counseling Information Form
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)
4. Email
(Last, First, MI)
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
rd
number. Comments on the burden should be sent to: U.S. Small Business Administration, 409 3
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
13. Client Signature
Date:
Date:
Time:
PART II: Client Intake (to be completed by all Clients)
14. Race (mark one or more)
15. Ethnicity
16.Gender
17. Do you consider
American Indian or Alaska Native
Male
yourself a person with
Hispanic or Latino
Asian
Not Hispanic or
a disability?
Black or African American
Female
Latino
Yes
No
Native Hawaiian or Other Pacific Islander
White
18. Veteran Status
Non-Veteran
Veteran
18a. Military Status
Member of Reserve or National Guard
Service-Disabled Veteran
On Active Duty
19. Referred by? (Mark all that apply)
Magazine/Newspaper
Other (specify)
SBA District
SBDC
Other Client
Word of Mouth
Lender
USFAC
Educational Institution
Television/Radio
Business Owner
SCORE
Local Economic Development Official
Internet (please indicate website)
SBA Web site
WBC
Chamber of Commerce
20a. Are you currently in business?
Yes
No (if no, skip to 30)
20b. If yes, are you currently exporting?
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
24. Date Business
25. Do you conduct
26a. Are you a home based business
Yes
No
your business is male or female owned?
business online?
Started?(MM/YYYY)
26b. Are you 8(a) certified?
Yes
No
__________% Male__________% Female
Yes
No
28a. For your most recent full business year, what
27a. Total No. of Employees
29. What is the legal entity of your business?
were your:
Gross Revenues/Sales $
(full & PT)
Sole Proprietorship
Corporation
LLC
+Profits/-Losses $
S-Corporation
Partnership
27b. Of total employees, how many are
28b. Amount of your Gross Revenues/Sales
Other (specify) ________________________________
engaged in the exporting aspect of your
business: (Full & PT)
related to exporting $
30. What is the nature of counseling you are seeking? (Choose primary category)
Start-up Assistance (How do I start a
Human Resources/
Marketing/Sales (promotion, market
Technology/Computers
small business?)
Managing Employees
research, pricing, etc.)
eCommerce (using the
Business Plan
Customer Relations
Government Contracting (including
Internet to do business)
Financing/Capital (such as applying
Business Accounting/
certifications)
Legal Issues (such as,
for a loan, building equity capital)
Budget
Franchising
Should I incorporate?)
Managing a Business
Cash Flow Management
Buy/Sell Business
International Trade
Tax Planning
Describe specific assistance requested in the space provided. ___________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
SBA Form 641 (07/31/2011)
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