U.S. Small Business Administration Counseling Information Form
U.S. Small Business Administration Counseling Information Form
U.S. Small Business Administration Counseling Information Form
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REQUEST FOR CONSULTATION<br />
1. Name of the Office Providing the Service: Terra State Community College 1a. Type of Client: Face to Face Online Telephone<br />
PART I: Client Request for <strong>Counseling</strong><br />
2. Client Name (Name of the person completing the form/representative of the business) 3. Email<br />
(Last, First, MI)<br />
4. Telephone 5. Fax<br />
Work Cell Home<br />
6. Street Address/PO Box (Give business address if currently in business) 7. City 8. State 9. Zip 10. +4<br />
PART II: Client Intake (To be completed by all Clients)<br />
11. Race (Mark one or more) Black or African American<br />
American Indian or Alaska Native Native Hawaiian or Other Pacific Islander<br />
Asian<br />
White<br />
12. Ethnicity<br />
Hispanic or Latino<br />
Not Hispanic or Latino<br />
13.Gender<br />
Male<br />
Female<br />
14. Are you a person with<br />
a disability?<br />
Yes No<br />
15. Veteran Status:<br />
15a. Military Status Member of Reserve or National Guard<br />
Veteran Non-Veteran Service-Disabled Veteran<br />
On Active Duty<br />
16. Referred by? (Mark all that apply) SBA Web site Chamber of Commerce Internet ____________<br />
SBA District Office SBDC Other Client Magazine/Newspaper Other (specify) _____________<br />
Lender USEAC Educational Institution Word of Mouth<br />
<strong>Business</strong> Owner SCORE Local Economic Development Official Television/Radio<br />
17a. Are you currently in business? Yes No (if no, skip to 29)<br />
17b. If yes, are you currently exporting? Yes No<br />
If yes to 17b, please go to Appendix A and indicate the markets to which your company currently exports (mark all that apply).<br />
18. Name of <strong>Business</strong><br />
19. Type of <strong>Business</strong> (choose primary category) 44 Retail Trade 56 Administrative & Support<br />
11Agriculture, Forestry/Fishing/ Hunting 48 Transportation & Warehousing 61 Educational Services<br />
21Mining 51 <strong>Information</strong> 62 Health Care & Social Assistance<br />
22Utilities 52 Finance & Insurance 71 Arts, Entertainment & Recreation<br />
23Construction 53 Real Estate & Rental & Leasing 72 Accommodation & Food Services<br />
31Manufacturing 54 Professional, Scientific & Technical Services 81 Other Services (except Public <strong>Administration</strong>)<br />
42Wholesale Trade 55 Management of Companies & Enterprises 92 Public <strong>Administration</strong><br />
20. <strong>Business</strong> Ownership What percentage of<br />
your business is male or female owned?<br />
__________% Male__________% Female<br />
24. <strong>Business</strong> Status:<br />
Pre-venture (Nascent) Existing-Healthy<br />
Start-up<br />
Existing-Declining<br />
26a. Total No. of Employees<br />
FT________ PT________<br />
26b. Of total employees, how many are<br />
engaged in the exporting aspect of your<br />
business?<br />
FT_________ PT__________<br />
21. Date <strong>Business</strong> 22. Do you conduct 23a. Are you a homebased business? Yes No<br />
Started?(MM/YYYY) business online? 23b. Are you 8(a) certified? Yes No<br />
based Yes business? No<br />
25a. Do you have a website? Yes No<br />
25b. Website:<br />
27a. For your most recent full business year, what<br />
were your:<br />
Gross Revenues/Sales $__________________<br />
28. What is the legal entity of your business?<br />
Sole Proprietorship<br />
LLC<br />
Partnership<br />
Corporation<br />
S-Corporation<br />
Other (specify) ________________<br />
+Profits/-Losses $___________________<br />
27b. Amount of your Gross Revenues/Sales related<br />
to exporting<br />
$__________________<br />
29. What is the nature of counseling you are seeking? (Choose primary category)<br />
200 Computer Systems 1200 <strong>Business</strong> Start-up 2200 eVantage 3300 Commercialization<br />
300 Engineering R&D 1300 Sources of Capital 2400 Women’s Certification 3400 Customer Relations<br />
400 Financial Analysis 1400 Technology 2500 <strong>Business</strong> Planning 3500 Franchising<br />
500 Human Resources 1500 Legal Issues 2600 CDBG 3600 Intellectual Property<br />
600 Buy/Sell <strong>Business</strong> 1600 Accounting/Budget 2700 RGP Launch 3800 ITAC-Research<br />
700 Government Contracting<br />
800 Export Assistance<br />
900 Inventory Control<br />
1000 Marketing Planning<br />
1100 Regulatory Compliance<br />
1700 Other<br />
1800 Export Launch<br />
1900 SBIR<br />
2000 Fed & St Technology<br />
2100 Case Management<br />
30. Current or previous association with Terra State Community College:<br />
2800 Agri<strong>Business</strong><br />
2900 No Response<br />
3000 Access to Capital-Debt<br />
3100 Access to Capital-Equity<br />
3200 Cash Flow<br />
3900 Management/Leadership<br />
4000 Market Diversification<br />
4100 Operation Analysis<br />
4200 Strategic Planning<br />
4300 Tax Planning<br />
Ohio Client Intake <strong>Form</strong> 641 1<br />
Updated: 03/2013
REQUEST FOR CONSULTATION<br />
Appendix A to Questions 17b. & 26b.<br />
If your company is currently exporting, please indicate the countries to which your company exports: (Mark all that apply)<br />
Asia Africa Caribbean Central America North America<br />
Afghanistan<br />
Bahrain<br />
Algeria<br />
Angola<br />
Anguilla<br />
Antigua & Barbuda<br />
Belize<br />
Costa Rica<br />
Bermuda<br />
Canada<br />
Bangladesh<br />
Benin<br />
Aruba<br />
El Salvador<br />
Belarus<br />
Botswana<br />
Bahamas<br />
Guatemala<br />
Bhutan<br />
Burkina Faso<br />
Barbados<br />
Honduras<br />
Brunei<br />
Burundi<br />
Virgin Islands<br />
Mexico<br />
Burma<br />
Cameroon<br />
(British)<br />
Nicaragua<br />
Cambodia<br />
Cape Verde<br />
Cayman Islands<br />
Panama<br />
China<br />
Central African<br />
Cuba<br />
East Timor Republic<br />
Dominica<br />
Georgia<br />
Chad<br />
Dominican Republic Europe South America<br />
Hong Kong<br />
India<br />
Indonesia<br />
Iran<br />
Iraq<br />
Israel<br />
Japan<br />
Jordan<br />
Kazakhstan<br />
Korea, North<br />
Korea, South<br />
Kuwait<br />
Comoros<br />
Congo<br />
Democratic<br />
Republic of Congo<br />
Cote d’Ivoire<br />
Djibouti<br />
Egypt<br />
Equatorial Guinea<br />
Eritrea<br />
Ethiopia<br />
Gabon<br />
Gambia<br />
Grenada<br />
Haiti<br />
Jamaica<br />
Montserrat<br />
Netherlands Antilles<br />
St. Kitts and Nevis<br />
St. Lucia<br />
St. Vincent and<br />
Grenadines<br />
Trinidad and Tobago<br />
Austria<br />
Azerbaijan<br />
Albania<br />
Armenia<br />
Belgium<br />
Bosnia-<br />
Herzegovina<br />
Bulgaria<br />
Croatia<br />
Cyprus<br />
Czech Republic<br />
Denmark<br />
Argentina<br />
Bolivia<br />
Brazil<br />
Chile<br />
Colombia<br />
Ecuador<br />
Guyana<br />
Paraguay<br />
Peru<br />
Suriname<br />
Uruguay<br />
Venezuela<br />
Kyrgyzstan<br />
Ghana<br />
Estonia<br />
Laos<br />
Guinea<br />
Oceania<br />
Finland<br />
Lebanon<br />
Guinea-Bissau<br />
Australia<br />
France<br />
Macau<br />
Kenya<br />
New Zealand<br />
Germany<br />
Malaysia<br />
Lesotho<br />
Cook Islands<br />
Greece<br />
Maldives<br />
Liberia<br />
Fiji<br />
Hungary<br />
Micronesia<br />
Libya<br />
Kiribati<br />
Iceland<br />
Mongolia<br />
Madagascar<br />
Marshall Islands<br />
Ireland<br />
Nepal<br />
Malawi<br />
Nauru<br />
Latvia<br />
Oman<br />
Mali<br />
Palau<br />
Liechtenstein<br />
Pakistan<br />
Mauritania<br />
Papua New<br />
Lithuania<br />
Philippines<br />
Mauritius<br />
Guinea<br />
Luxembourg<br />
Qatar<br />
Morocco<br />
Samoa<br />
Macedonia<br />
Russia<br />
Mozambique<br />
Solomon Islands<br />
Malta<br />
Saudi Arabia<br />
Namibia<br />
Tonga<br />
Moldova<br />
Singapore<br />
Niger<br />
Tuvalu<br />
Monaco<br />
Sri Lanka<br />
Nigeria<br />
Vanuatu<br />
Montenegro<br />
Syria<br />
Tajikistan<br />
Taiwan<br />
Thailand<br />
Turkey<br />
Turkmenistan<br />
Rwanda<br />
Sao Tome and<br />
Principe<br />
Senegal<br />
Seychelles<br />
Sierra Leone<br />
Netherlands<br />
Norway<br />
Poland<br />
Portugal<br />
Romania<br />
Serbia<br />
Other<br />
Subcontractor for<br />
United Arab<br />
Somalia<br />
Slovak Republic Exporter<br />
Emirates<br />
South Africa<br />
Slovenia<br />
Sell to fill-freight<br />
Uzbekistan<br />
Vietnam<br />
Yemen<br />
Sudan<br />
Swaziland<br />
Tanzania<br />
Togo<br />
Tunisia<br />
Uganda<br />
Zambia<br />
Zimbabwe<br />
Spain<br />
Sweden<br />
Switzerland<br />
Turkey<br />
Ukraine<br />
United Kingdom<br />
Vatican City<br />
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<br />
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<br />
DO NOT SEND FORMS TO OMB.<br />
Ohio Client Intake <strong>Form</strong> 641 2<br />
Updated: 03/2013
REQUEST FOR CONSULTATION<br />
31. Date Counseled (MM/YYYY) 32. Language(s) Used:<br />
English Spanish Other (specify)____________<br />
33. History<br />
New Case Follow-up One Time<br />
34. Counselor(s) Name (If multiple counselors, list lead counselor first and separate<br />
each additional counselor name by a semi-colon):<br />
35a. Contact Hours 35b. Prep Hours<br />
35c. Travel Hours Total amount of time it takes to travel to a client’s location for counseling. Miles ______ Hours________<br />
36. Referred Client to (Mark all that apply): ITAC MTSBDC PTAC MEP/Technology<br />
WBC SBA District Office Export/Import Bank Dept of Commerce Export Assistance<br />
SCORE USEAC OPIC Dept of State Other_________________<br />
SESSION NOTES -- STRATEGIC COUNSELING FORMAT<br />
Initial Session:<br />
The INITIAL SESSION with a client MUST include the following documentation in the notes field in Center IC in the following order:<br />
1. DESCRIPTION of the client’s business – short, concise and thorough.<br />
2. ANALYSIS/statement of the problem(s) to be solved.<br />
3. SESSION SUMMARY/ACTIONS TAKEN of what occurred in the session (discussion talking points, brainstorming, etc.)<br />
4. PLANNED ACTIONS/NEXT STEPS to be taken prior to the next session to address the problem (spreadsheet developed, assessment performed, business plan<br />
outlined, etc.)<br />
5. GOALS set for the client and the business advisor to achieve overall objectives.<br />
DID YOU COMPLETE THE BASELINE ECONOMIC INDICATORS? Yes No<br />
Follow-on Session:<br />
The FOLLOW-ON SESSIONS with a client MUST include the following documentation in the notes field in Center IC in the following<br />
order:<br />
1. PROGRESS made since the last session on actions assigned.<br />
2. SESSION SUMMARY/ACTIONS TAKEN of what occurred in the session (discussion talking points, brainstorming, review of business plan draft, etc.).<br />
3. PLANNED ACTIONS/NEXT STEPS plan to move forward, the next steps for the client and the business advisor.<br />
4. GOAL UPDATES includes any updates or revisions to the goals set in the initial session.<br />
5. DOCUMENTS attached any electronic files as well as indicate what paper documents were added to the client’s file.<br />
DID YOU ADD ANY NEW ECONOMIC INDICATORS? Yes No<br />
Ohio Client Intake <strong>Form</strong> 641 3<br />
Updated: 03/2013
CLIENT RIGHTS &<br />
RESPONSIBILITIES<br />
Funded in part through<br />
a cooperative<br />
agreement with SBA<br />
As a new client of the Ohio <strong>Small</strong> <strong>Business</strong> Development Center (SBDC), we'd like to advise you of certain<br />
rights and responsibilities you have as one of our clients:<br />
You have a right to expect:<br />
Prompt, courteous, and professional counseling services and to be advised if the Ohio SBDC is unable to provide<br />
service within the time frame required. Be aware that due to the demand for our services, cases must often<br />
be prioritized by need and training may be recommended before counseling is provided.<br />
All information shared with the Ohio SBDC and any of its resources (staff, faculty, volunteers, and consultants) will be<br />
held in strictest confidence. No information provided by you will be used to the commercial advantage of any staff<br />
member, consultant, or other resource of the Ohio SBDC or to the benefit of any third party.<br />
That your client status with the Ohio SBDC will remain confidential. No public use of your name, address, or business<br />
identity will be made without your prior approval. Please note, however, that the Ohio SBDC is funded in part by the<br />
U.S. <strong>Small</strong> <strong>Business</strong> <strong>Administration</strong>, Ohio Development Services Agency and the local host, only aggregate client data<br />
is provided to those entities.<br />
Our role is to counsel and assist small business owners and those planning to go into business. We will not make<br />
business decisions or judgments for you, though we will make recommendations and suggestions as appropriate. These<br />
will be based upon our best efforts to apply the experience and resources available to us to assist you in making your<br />
own business decisions.<br />
The Ohio SBDC may charge reasonable fees for training programs, special services, and publications. However, you have<br />
a right to feel secure that no fee will be charged by the Ohio SBDC or its resources for normal counseling services<br />
provided to you. Also, no recommendations will be made as to the purchase of goods or services from any individual or<br />
firm with whom any Ohio SBDC staff or its resources have any financial, familial or personal interest.<br />
The counseling services provided to you are a part of the effort of the Ohio SBDC and its sponsors to respond to the<br />
growing needs of the small business community and to positively affect the economy of Ohio. They are not<br />
intended to compete with, replace, or be a substitute for services available from the private sector. Clients whose needs<br />
can be fully met by private sector practitioners or firms in an affordable manner will be encouraged to use those<br />
resources.<br />
In consideration of the Ohio SBDC furnishing you with management and technical assistance, you agree to waive all<br />
claims against the Ohio SBDC and its constituent institutions, its staff, or any other resources employed by or used in<br />
connection with these services. You will also be expected to cooperate with the OHIO SBDC in its efforts to assure the<br />
quality and effectiveness of the counseling services it provides.<br />
In this respect, the Ohio SBDC will ask all clients who receive counseling assistance to complete a written evaluation of<br />
the services provided. In addition, clients may receive direct inquires from this office, the State Director's office or the<br />
U.S. <strong>Small</strong> <strong>Business</strong> <strong>Administration</strong> with respect to the services provided to you. Your response to all of these inquiries<br />
will be greatly appreciated.<br />
REQUEST FOR CONSULTATION<br />
SBDC Agreement:<br />
I request business counsultation service from the Ohio SBDC, a Resource Partner of the <strong>Small</strong> <strong>Business</strong> <strong>Administration</strong> (SBA). I agree to cooperate<br />
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<br />
and information mailings regarding products and services ( Yes No). I understand that any information disclosed will be held in strict confidence.<br />
The SBDC will not provide your personal information to commercial entities.) I authorize the Ohio SBDC to furnish relevant information to the assigned<br />
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<br />
an interest, and 2) accept fees or commissions developing from this counseling relationship. In consideration of the counselor(s) furnishing management<br />
or technical assistance, I waive all claims against SBDC personnel, and that of its Resource Partners and host organizations, arising from this assistance.<br />
*_______________________________________________<br />
Client Signature<br />
_______________________________________________<br />
Counselor Signature<br />
*__________________________________<br />
Date
Request for Consultation<br />
(Optional)<br />
Funded in part through a<br />
cooperative agreement with<br />
SBA<br />
Request for services beyond the core Ohio SBDC program offered in<br />
collaboration with Ohio Development Services Agency Resource Partners<br />
Ohio SBDC Expanded Services Agreement:<br />
I am requesting business services beyond the core Ohio SBDC program that are offered in collaboration with<br />
other Ohio Development Services Agency partners. Such partners may include: Ohio SBDC’s International<br />
Trade Assistance Center (ITAC) and State Trade and Export Promotion Grant Program (STEP); and/or Ohio<br />
Manufacturing and Technology <strong>Small</strong> <strong>Business</strong> Development Centers (MTSBDC) in conjunction with the U. S.<br />
Department of Commerce’s National Institute of Standards - Manufacturing Extension Partnership (MEP);<br />
and/or other offices within the Ohio Development Services Agency. I agree to cooperate should I be selected<br />
to participate in surveys designed to evaluate these services. I permit the Ohio SBDC the use of my name and<br />
address for surveys and information mailings regarding these products and services ( Yes No). I<br />
understand that any information disclosed will be held in strict confidence. The SBDC will not provide your<br />
personal information to commercial entities.) I authorize the Ohio SBDC to furnish relevant information to the<br />
assigned management counselor(s). I further understand that the counselor(s) agrees not to: 1) recommend<br />
goods or services from sources in which he/she has an interest, and 2) accept fees or commissions developing<br />
from this counseling relationship. In consideration of the counselor(s) furnishing management or technical<br />
assistance, I waive all claims against SBDC personnel, and that of its Resource Partners and host<br />
organizations, arising from this assistance.<br />
*_______________________________________________<br />
Client Signature<br />
*__________________________________<br />
Date<br />
_______________________________________________<br />
Counselor Signature<br />
We welcome you as a client and encourage you to call on us if you have any questions<br />
or comments with regard to your rights and responsibilities or services you receive.<br />
You can do so by calling your local Ohio SBDC counselor or the Ohio SBDC State Office<br />
at (614) 466-2711.