Request for Counseling (Form 641)

Please complete this form to request counseling from our SBDC.

Items marked with * are required to complete.

The more detail you can provide us about your counseling needs, we will be able to assign the proper counselor.

Click Finish to send us the form.

1. First Name
2. Last Name
3. Email Address
4. Telephone Work
5. Telephone Home
6. Telephone Cell
7. Fax
8. Company Name
9. Home Mailing Address
10. Home City
11. Home State
12. Home Zip
13. Company Mailing Address
14. Company City
15. Company State
16. Company Zip Code
17. County
18. Company Website
19. Gender Please select... Male Female
20. Ethnic Group Please select... Hispanic/Latino Asian Black/African American White/Caucasian Native American Pacific Islander Other
21. Veteran Status Please select... Non-Veteran Veteran Service Disabled Veteran
22. Reservist Status Please select... National Guard National Guard Active Duty Reservist Reservist Active Duty
23. Disabled Please select... Yes No
24. Business Status Please select... Pre-Venture (not in business) Start-up (0 to 2 years) Established (over 2 years) High Growth (over 2 years) Mature (over 5 years)
25. International Trade (Import/Export) Please select... Yes No
26. Language Used Please select... English Spanish Korean Cantonese Mandarin Other
27. Date Business Established
28. Legal Entity of Your business Please select... Sole Propietorship Partnership General Partnership Limited Partnership Limited Liability Corporation Corporation Sub S Corporation Non-Profit
29. Number of Employees Full Time
30. Number of Part-Time Employees
31. Annual Sales (last 12 months)
32. Business Ownership Please select... Male (51%+) Female (51%+) Male/Female (50/50)
33. Business Certification Please select... None Certified Small Business Certified SBA 8(a) Small Business Disadvantaged Small Business Minority Owned Small Business Women Owned Small Business Other Small Business Large Business
34. Are you doing business online? Please select... Yes No
35. Are you a home-based business? Please select... Yes No
36. Please describe your type of business
37. Please describe your product or service
38. How did you find us? Please select... Internet Flyer Mailer Seminar SBA - SCORE Word of Mouth College-University Chamber of Commerce Bank TV/Radio Newspapers Other SBDC City - Government Agency SBDC Client Other
39. Please describe your counseling needs here
    _{The more detailed the better so we can assign you the proper counselor.}
40. Electronic Signature:

    By Typing my name here, I request business management assistance from the El Camino College SBDC - The Small Business Administration (SBA)/Small Business Development Center (SBDC).

    I agree to cooperate should I be selected to participate in surveys designed to evaluate SBDC assistance services.

    I authorize the SBA/SBDC to furnish relevant information to the assigned management counselor(s), although I expect that information to be held in strict confidence by him/her.

    I further understand that all counselors have agreed no to recommend goods or services from sources in which they have an interest. SBA/SBDC will not accept fees or commissions developing from this counseling relationship.

    By my electronic signature below, and in consideration of the center's furnishing of management or technical assistance, I waive all claims against SBA, SCORE, SBDC, El Camino College and other related organizations.

    I understand that there are no warranties or assurances in connection with the counseling assistance.

    PLEASE TYPE YOUR NAME AND DATE BELOW.
    THIS IS YOUR ELECTRONIC SIGNATURE.

    Signature
41. Date
42. Best way to contact you Please select... Phone Email Other
43. Best time to schedule an appointment with our counselors Please select... Morning (8AM to 12Noon) Afternoon (12Noon to 5PM) Evening (after 5PM) (if available) Saturday (if available)