U.S. Small Business Administration Counseling Information Form

REQUEST FOR CONSULTATION
1. Name of the Office Providing the Service: Terra State Community College 1a. Type of Client: Face to Face Online Telephone
PART I: Client Request for Counseling
2. Client Name (Name of the person completing the form/representative of the business) 3. Email
(Last, First, MI)
4. Telephone 5. Fax
Work Cell Home
6. Street Address/PO Box (Give business address if currently in business) 7. City 8. State 9. Zip 10. +4
PART II: Client Intake (To be completed by all Clients)
11. Race (Mark one or more) Black or African American
American Indian or Alaska Native Native Hawaiian or Other Pacific Islander
Asian
White
12. Ethnicity
Hispanic or Latino
Not Hispanic or Latino
13.Gender
Male
Female
14. Are you a person with
a disability?
Yes No
15. Veteran Status:
15a. Military Status Member of Reserve or National Guard
Veteran Non-Veteran Service-Disabled Veteran
On Active Duty
16. Referred by? (Mark all that apply) SBA Web site Chamber of Commerce Internet ____________
SBA District Office SBDC Other Client Magazine/Newspaper Other (specify) _____________
Lender USEAC Educational Institution Word of Mouth
Business Owner SCORE Local Economic Development Official Television/Radio
17a. Are you currently in business? Yes No (if no, skip to 29)
17b. If yes, are you currently exporting? Yes No
If yes to 17b, please go to Appendix A and indicate the markets to which your company currently exports (mark all that apply).
18. Name of Business
19. Type of Business (choose primary category) 44 Retail Trade 56 Administrative & Support
11Agriculture, Forestry/Fishing/ Hunting 48 Transportation & Warehousing 61 Educational Services
21Mining 51 Information 62 Health Care & Social Assistance
22Utilities 52 Finance & Insurance 71 Arts, Entertainment & Recreation
23Construction 53 Real Estate & Rental & Leasing 72 Accommodation & Food Services
31Manufacturing 54 Professional, Scientific & Technical Services 81 Other Services (except Public Administration)
42Wholesale Trade 55 Management of Companies & Enterprises 92 Public Administration
20. Business Ownership What percentage of
your business is male or female owned?
__________% Male__________% Female
24. Business Status:
Pre-venture (Nascent) Existing-Healthy
Start-up
Existing-Declining
26a. Total No. of Employees
FT________ PT________
26b. Of total employees, how many are
engaged in the exporting aspect of your
business?
FT_________ PT__________
21. Date Business 22. Do you conduct 23a. Are you a homebased business? Yes No
Started?(MM/YYYY) business online? 23b. Are you 8(a) certified? Yes No
based Yes business? No
25a. Do you have a website? Yes No
25b. Website:
27a. For your most recent full business year, what
were your:
Gross Revenues/Sales $__________________
28. What is the legal entity of your business?
Sole Proprietorship
LLC
Partnership
Corporation
S-Corporation
Other (specify) ________________
+Profits/-Losses $___________________
27b. Amount of your Gross Revenues/Sales related
to exporting
$__________________
29. What is the nature of counseling you are seeking? (Choose primary category)
200 Computer Systems 1200 Business Start-up 2200 eVantage 3300 Commercialization
300 Engineering R&D 1300 Sources of Capital 2400 Women’s Certification 3400 Customer Relations
400 Financial Analysis 1400 Technology 2500 Business Planning 3500 Franchising
500 Human Resources 1500 Legal Issues 2600 CDBG 3600 Intellectual Property
600 Buy/Sell Business 1600 Accounting/Budget 2700 RGP Launch 3800 ITAC-Research
700 Government Contracting
800 Export Assistance
900 Inventory Control
1000 Marketing Planning
1100 Regulatory Compliance
1700 Other
1800 Export Launch
1900 SBIR
2000 Fed & St Technology
2100 Case Management
30. Current or previous association with Terra State Community College:
2800 AgriBusiness
2900 No Response
3000 Access to Capital-Debt
3100 Access to Capital-Equity
3200 Cash Flow
3900 Management/Leadership
4000 Market Diversification
4100 Operation Analysis
4200 Strategic Planning
4300 Tax Planning
Ohio Client Intake Form 641 1
Updated: 03/2013

REQUEST FOR CONSULTATION
Appendix A to Questions 17b. & 26b.
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
Bahrain
Algeria
Angola
Anguilla
Antigua & Barbuda
Belize
Costa Rica
Bermuda
Canada
Bangladesh
Benin
Aruba
El Salvador
Belarus
Botswana
Bahamas
Guatemala
Bhutan
Burkina Faso
Barbados
Honduras
Brunei
Burundi
Virgin Islands
Mexico
Burma
Cameroon
(British)
Nicaragua
Cambodia
Cape Verde
Cayman Islands
Panama
China
Central African
Cuba
East Timor Republic
Dominica
Georgia
Chad
Dominican Republic Europe South America
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
Korea, North
Korea, South
Kuwait
Comoros
Congo
Democratic
Republic of Congo
Cote d’Ivoire
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Grenada
Haiti
Jamaica
Montserrat
Netherlands Antilles
St. Kitts and Nevis
St. Lucia
St. Vincent and
Grenadines
Trinidad and Tobago
Austria
Azerbaijan
Albania
Armenia
Belgium
Bosnia-
Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Kyrgyzstan
Ghana
Estonia
Laos
Guinea
Oceania
Finland
Lebanon
Guinea-Bissau
Australia
France
Macau
Kenya
New Zealand
Germany
Malaysia
Lesotho
Cook Islands
Greece
Maldives
Liberia
Fiji
Hungary
Micronesia
Libya
Kiribati
Iceland
Mongolia
Madagascar
Marshall Islands
Ireland
Nepal
Malawi
Nauru
Latvia
Oman
Mali
Palau
Liechtenstein
Pakistan
Mauritania
Papua New
Lithuania
Philippines
Mauritius
Guinea
Luxembourg
Qatar
Morocco
Samoa
Macedonia
Russia
Mozambique
Solomon Islands
Malta
Saudi Arabia
Namibia
Tonga
Moldova
Singapore
Niger
Tuvalu
Monaco
Sri Lanka
Nigeria
Vanuatu
Montenegro
Syria
Tajikistan
Taiwan
Thailand
Turkey
Turkmenistan
Rwanda
Sao Tome and
Principe
Senegal
Seychelles
Sierra Leone
Netherlands
Norway
Poland
Portugal
Romania
Serbia
Other
Subcontractor for
United Arab
Somalia
Slovak Republic Exporter
Emirates
South Africa
Slovenia
Sell to fill-freight
Uzbekistan
Vietnam
Yemen
Sudan
Swaziland
Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Spain
Sweden
Switzerland
Turkey
Ukraine
United Kingdom
Vatican City
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 number. Comments on the burden should be sent to: Ohio SBDC at Ohio Development Services Agency, 77 S. High St., 28 th Floor Columbus, OH 43215. PLEASE
DO NOT SEND FORMS TO OMB.
Ohio Client Intake Form 641 2
Updated: 03/2013

REQUEST FOR CONSULTATION
31. Date Counseled (MM/YYYY) 32. Language(s) Used:
English Spanish Other (specify)____________
33. History
New Case Follow-up One Time
34. Counselor(s) Name (If multiple counselors, list lead counselor first and separate
each additional counselor name by a semi-colon):
35a. Contact Hours 35b. Prep Hours
35c. Travel Hours Total amount of time it takes to travel to a client’s location for counseling. Miles ______ Hours________
36. Referred Client to (Mark all that apply): ITAC MTSBDC PTAC MEP/Technology
WBC SBA District Office Export/Import Bank Dept of Commerce Export Assistance
SCORE USEAC OPIC Dept of State Other_________________
SESSION NOTES -- STRATEGIC COUNSELING FORMAT
Initial Session:
The INITIAL SESSION with a client MUST include the following documentation in the notes field in Center IC in the following order:
1. DESCRIPTION of the client’s business – short, concise and thorough.
2. ANALYSIS/statement of the problem(s) to be solved.
3. SESSION SUMMARY/ACTIONS TAKEN of what occurred in the session (discussion talking points, brainstorming, etc.)
4. PLANNED ACTIONS/NEXT STEPS to be taken prior to the next session to address the problem (spreadsheet developed, assessment performed, business plan
outlined, etc.)
5. GOALS set for the client and the business advisor to achieve overall objectives.
DID YOU COMPLETE THE BASELINE ECONOMIC INDICATORS? Yes No
Follow-on Session:
The FOLLOW-ON SESSIONS with a client MUST include the following documentation in the notes field in Center IC in the following
order:
1. PROGRESS made since the last session on actions assigned.
2. SESSION SUMMARY/ACTIONS TAKEN of what occurred in the session (discussion talking points, brainstorming, review of business plan draft, etc.).
3. PLANNED ACTIONS/NEXT STEPS plan to move forward, the next steps for the client and the business advisor.
4. GOAL UPDATES includes any updates or revisions to the goals set in the initial session.
5. DOCUMENTS attached any electronic files as well as indicate what paper documents were added to the client’s file.
DID YOU ADD ANY NEW ECONOMIC INDICATORS? Yes No
Ohio Client Intake Form 641 3
Updated: 03/2013

CLIENT RIGHTS &
RESPONSIBILITIES
Funded in part through
a cooperative
agreement with SBA
As a new client of the Ohio Small Business Development Center (SBDC), we'd like to advise you of certain
rights and responsibilities you have as one of our clients:
You have a right to expect:
Prompt, courteous, and professional counseling services and to be advised if the Ohio SBDC is unable to provide
service within the time frame required. Be aware that due to the demand for our services, cases must often
be prioritized by need and training may be recommended before counseling is provided.
All information shared with the Ohio SBDC and any of its resources (staff, faculty, volunteers, and consultants) will be
held in strictest confidence. No information provided by you will be used to the commercial advantage of any staff
member, consultant, or other resource of the Ohio SBDC or to the benefit of any third party.
That your client status with the Ohio SBDC will remain confidential. No public use of your name, address, or business
identity will be made without your prior approval. Please note, however, that the Ohio SBDC is funded in part by the
U.S. Small Business Administration, Ohio Development Services Agency and the local host, only aggregate client data
is provided to those entities.
Our role is to counsel and assist small business owners and those planning to go into business. We will not make
business decisions or judgments for you, though we will make recommendations and suggestions as appropriate. These
will be based upon our best efforts to apply the experience and resources available to us to assist you in making your
own business decisions.
The Ohio SBDC may charge reasonable fees for training programs, special services, and publications. However, you have
a right to feel secure that no fee will be charged by the Ohio SBDC or its resources for normal counseling services
provided to you. Also, no recommendations will be made as to the purchase of goods or services from any individual or
firm with whom any Ohio SBDC staff or its resources have any financial, familial or personal interest.
The counseling services provided to you are a part of the effort of the Ohio SBDC and its sponsors to respond to the
growing needs of the small business community and to positively affect the economy of Ohio. They are not
intended to compete with, replace, or be a substitute for services available from the private sector. Clients whose needs
can be fully met by private sector practitioners or firms in an affordable manner will be encouraged to use those
resources.
In consideration of the Ohio SBDC furnishing you with management and technical assistance, you agree to waive all
claims against the Ohio SBDC and its constituent institutions, its staff, or any other resources employed by or used in
connection with these services. You will also be expected to cooperate with the OHIO SBDC in its efforts to assure the
quality and effectiveness of the counseling services it provides.
In this respect, the Ohio SBDC will ask all clients who receive counseling assistance to complete a written evaluation of
the services provided. In addition, clients may receive direct inquires from this office, the State Director's office or the
U.S. Small Business Administration with respect to the services provided to you. Your response to all of these inquiries
will be greatly appreciated.
REQUEST FOR CONSULTATION
SBDC Agreement:
I request business counsultation service from the Ohio SBDC, a Resource Partner of the Small Business Administration (SBA). I agree to cooperate
should I be selected to participate in surveys designed to evaluate SBA services. I permit the Ohio SBDC the use of my name and address for surveys
and information mailings regarding products and services ( Yes No). I understand that any information disclosed will be held in strict confidence.
The SBDC will not provide your personal information to commercial entities.) I authorize the Ohio SBDC 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 SBDC personnel, and that of its Resource Partners and host organizations, arising from this assistance.
*_______________________________________________
Client Signature
_______________________________________________
Counselor Signature
*__________________________________
Date

Request for Consultation
(Optional)
Funded in part through a
cooperative agreement with
SBA
Request for services beyond the core Ohio SBDC program offered in
collaboration with Ohio Development Services Agency Resource Partners
Ohio SBDC Expanded Services Agreement:
I am requesting business services beyond the core Ohio SBDC program that are offered in collaboration with
other Ohio Development Services Agency partners. Such partners may include: Ohio SBDC’s International
Trade Assistance Center (ITAC) and State Trade and Export Promotion Grant Program (STEP); and/or Ohio
Manufacturing and Technology Small Business Development Centers (MTSBDC) in conjunction with the U. S.
Department of Commerce’s National Institute of Standards - Manufacturing Extension Partnership (MEP);
and/or other offices within the Ohio Development Services Agency. I agree to cooperate should I be selected
to participate in surveys designed to evaluate these services. I permit the Ohio SBDC the use of my name and
address for surveys and information mailings regarding these products and services ( Yes No). I
understand that any information disclosed will be held in strict confidence. The SBDC will not provide your
personal information to commercial entities.) I authorize the Ohio SBDC 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 SBDC personnel, and that of its Resource Partners and host
organizations, arising from this assistance.
*_______________________________________________
Client Signature
*__________________________________
Date
_______________________________________________
Counselor Signature
We welcome you as a client and encourage you to call on us if you have any questions
or comments with regard to your rights and responsibilities or services you receive.
You can do so by calling your local Ohio SBDC counselor or the Ohio SBDC State Office
at (614) 466-2711.