Client Intake Form - Advising South-West Texas Border Network Small Business Development Centers
Client Name (Last, First, MI) Email
Check here if you DO NOT want to receive emails from SBDC [ ] Mailing Address City, State, Zip Code (+4 if known)
Home Phone Cell Phone
Work Phone Fax
Race (mark one or more) Ethnicity Gender Do you consider Asian Native Hawaiian or Hispanic or Latino Male yourself a person Black or African American Other Pacific Islander Not Hispanic or Latino Female with a disability? Native American or Alaska Native White Yes No Veteran Status Non-Veteran Service-Disabled Veteran Military Status On Active Duty Veteran National Guard Reservist
What prompted you to contact us? (mark all that apply) Training Seminar Website Advertising/Marketing Client/ Word of Mouth Newspaper Yellow Pages Bank College University Local EDC Other (specify) ______Chamber of Commerce Email Media/TV/Radio Internet URL ______SBDC SBA Network
Special SBDC Client Types: (Office use) Bid Match Client Shale Gas/Oil Play Colonia SBDCGlobal.com 8 M Technology Client (SBIR/STTR) Rural Emergency Preparedness Mexican National Empowerment Zone HUB Zone Alumni
Are you currently in business? Yes. Please indicate Month/Year established: ______No (Please skip shaded area & sign form at bottom)
If in business, but want to explore new business, please specify area of interest:: ______
If in business, are you currently exporting? Yes. Please list the Countries below or check the Appendix page. No Not yet, but I’m interested. Countries: ______
Company Name (if applicable) Website
Position Owner of Sole Proprietorship Employee President Vice-President Partner Other: ______
Physical address of the business City State Zip (+4 if known)
Type of Business Manufacturing Wholesale Construction Retail Services Other:______
Products/Services: ______NAICS Code(s): ______
Business Ownership Do you conduct Home-based business? Are you 8(a) certified? SBA Relationship What is the gender of business ownership? business online? Applicant Borrower Male Yes No Yes No Yes No COC Female Male/Female ownership Procurement Assist. Date:______Technical Assistance Total # Employees: For your most recent full business year, what were your: What is the legal entity of your business?
______Full-time Gross Revenues/Sales (GRS) $______Sole Proprietorship Partnership ______Part-time S-Corporation LLC +Profits/-Losses $ ______Corporation ______How many are engaged Other: ______in the exporting aspect of business? Amount of GRS related to exporting? ______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 self-certify that neither I nor my company have been suspended or debarred by a federal agency. I understand that any information disclosed will be held in strict confidence, said information including but not limited to confidential and proprietary information in any form whatsoever, including oral, written and machine readable form. SBA will not provide your 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. I waive all claims against SBA personnel, resource partners and host organizations, arising from this assistance. The estimated burden for completing this form is 3 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. Client Signature Date:
Advisor: ______Client ID: ______
Client Intake SWTXB 641 FY15.doc
Appendix A (complete only if applicable) 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 Algeria Anguilla Belize Bermuda Bahrain Angola Antigua & Barbuda Costa Rica Canada Bangladesh Benin Aruba El Salvador Mexico Belarus Botswana Bahamas Guatemala Bhutan Burkina Faso Barbados Honduras Brunei Burundi Virgin Islands (British) Nicaragua Burma Cameroon Cayman Islands Panama Cambodia Cape Verde Cuba China Central African Republic Dominica Europe South America East Timor Chad Dominican Republic Georgia Comoros Grenada Austria Argentina Hong Kong Congo Haiti Azerbaijan Bolivia India Democratic Republic of Jamaica Albania Brazil Indonesia Congo Montserrat Armenia Chile Iran Cote d’Ivoire Netherlands Antilles Belgium Colombia Iraq Djibouti St. Kitts and Nevis Bosnia-Herzegovina Ecuador Israel Egypt St. Lucia Bulgaria Guyana Japan Equatorial Guinea St. Vincent and Croatia Paraguay Jordan Eritrea Grenadines Cyprus Peru Kazakhstan Ethiopia Trinidad and Tobago Czech Republic Suriname Korea, North Gabon Denmark Uruguay Korea, South Gambia Estonia Venezuela Kuwait Ghana Finland Kyrgyzstan Guinea France Oceania Laos Guinea-Bissau Germany Lebanon Kenya Hungary Australia Macau Lesotho Iceland New Zealand Malaysia Liberia Ireland Cook Islands Maldives Libya Italy Fiji Micronesia Madagascar Latvia Kiribati Mongolia Malawi Liechtenstein Marshall Islands Nepal Mali Lithuania Nauru Oman Mauritania Luxembourg Palau Pakistan Mauritius Macedonia Papua New Guinea Philippines Morocco Malta Samoa Qatar Mozambique Moldova Solomon Islands Russia Namibia Monaco Tonga Saudi Arabia Niger Montenegro Tuvalu Singapore Rwanda Netherlands Vanuatu Sri Lanka Sao Tome and Principe Norway Syria Senegal Poland Tajikistan Seychelles Portugal Other Taiwan Sierra Leone Romania Subcontractor for Thailand Somalia Serbia Exporter Turkey South Africa Slovak Republic Sell to fill-freight Turkmenistan Sudan Slovenia United Arab Emirates Swaziland Spain Uzbekistan Tanzania Sweden Vietnam Togo Switzerland Yemen Tunisia Turkey Uganda Ukraine Zambia United Kingdom Zimbabwe Vatican City