Menu Home Online Training Login Calendar < :: September, 2010 :: > S M T W T F S 29 30 31 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 01 02 Request for Counseling (Form 641) Page 1 of 1 Please complete this form to request counseling from the San Gabriel Valley SBDC. Items marked with a red * are required. Type n/a or NA (not applicable) if you do not have the information at this time. The more detail you can provide us about your counseling needs, the better, that way we will be able to assign you the proper counselor for your needs. We do not charge a fee for consulting or counseling services. Clients may be asked to take some of our trainings and courses, offered at no charge or at a very reasonable cost, before or after they receive consulting services so that they can make better use of the consulting input. Click 'Finish' to send us the form. Click here to read the Terms of Service and Disclaimers We look forward to be of service. 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 Male Female 20. Ethnic Group Hispanic/Latino Asian Black/African American White/Caucasian Native American Pacific Islander Other 21. Veteran Status Non-Veteran Veteran Service Disabled Veteran 22. Reservist Status National Guard National Guard Active Duty Reservist Reservist Active Duty 23. Disabled Yes No 24. * Business Status 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) Yes No 26. Language Used English Spanish Korean Cantonese Mandarin Other 27. * Date Business Established 28. * Legal Entity of your business 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 Male (51%+) Female (51%+) Male/Female (50/50) 33. Business Certification 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? Yes No 35. Are you a Home Based Business? Yes No 36. * Please describe your type of business 37. * Please describe your Product or Service 38. How did you find us? 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 MTSAC 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, MtSAC, LBCC 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. 41. * Please Type Today's Date 42. Best way to contact you Phone Email Other 43. Best time to schedule an appointment with our counselors Morning (8AM to 12Noon) Afternoon (12Noon to 5PM) Evening (after 5PM) (if available) Saturday (if available)

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