Form 641
1)
*Required 		First Name
Middle Initial
Last Name

2)
*Required
Home Phone
Business Phone
Fax
 10 Digit Phone Number Only
3) Email
 
4)
*Required 		Street Address
6) County
5)
*Required 		City
7)
*Required 		State
 
8)
*Required 		Zip
9) Race
 10) Ethnicity
 11)Gender
12) Do you consider yourself a person with a disability:
  Yes     No
13) Veteran Status
 14) Military Status
15) What prompted you to contact us? (mark all that apply)
SBA District    Lender    Business Owner    Television/Radio    Other Client    Magazine    Internet    Newspaper    Chamber of Commerce    Educational Institution    Local Economic Development Official    Word of Mouth    SBA Web site    Other (Specify)    
16) What is the nature of counseling you are seeking? (Choose primary category)

Describe specific assistance requested in the space provided. *Required
17) Are you currently in business? Yes No
*Required      ( If No, skip to line 27 ) 		18)  Home based business? Yes No
        Are you 8(a) Certified? Yes No
19) Type of Business:
 20) Do you conduct business online?
                                            Yes No
21) Name of Company: 22) Month &Year business started:
Format: mm/yyyy
23) Business Ownership - What percentage of your business is male or female ownership?:
% Male      % Female 		24) Total Number of Employees:
25) For your most recent full business year, what were your:
Gross Revenues/Sales $
+Profits/-Losses $
(No commas or dollar signs please) 		26) What is the legal entity of your business?:
27) Please select a convienient location, date, and time for your counseling appointment:
Location: Date: Time:
**For alternative dates and/or times, please call us at 434-295-6712 or E Mail to appointments@score-494.org.

I request business management counseling from a Small Business Administration 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 will be held in strict confidence by him/her.

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, SCORE and its host organizations, and other SBA Resource Counselors arising from this assistance.

Please note, by clicking the "Submit" button, you agree to the preceeding disclaimer.