SBDC CLIENT INFORMATION FORM

In order to request business counsulting from the Small Business Development Center, please complete the following Client Information Form (Step 1) and the Client Survey (Step 2). Your reponses will be kept confidential. Please fill in the areas marked A,B,C, and D. Thank you!
SBDC Office Use Only

Case Number:

Counselor:

Initial Contact Date

NAIC CODE:

Type of Action for Center 12011
      1.) One Time      2.) Initial      3.) Follow Up      4.)SCORE      5.) Youngstown SBA Initiative

A. Primary Contact Information

First Name:

Last Name:

Phone ( Home):

 Mailing Address (Street, City, State, Zip}:

Phone (Business):

Fax:

E-Mail:

Web Site:

Business Status:      Start-Up        Existing Healthy

Referred by:
B. Company Information (If Existing Business, fill out Company Information - Section D)

Company Name:

County:

Primary Location:
 

Form of Business Organization:

Business Type:

SBA Relationship:

New Product or Technology: 

  Yes          No

Do You Export?

  Yes          No

Defense Related:

  Yes          No

Briefly Describe Product/Service:
 
C. Owner(s) Information (Applies to Business Owner and Start-Up)

Gender:
 

Military Status:
 

Race:
 

Area of Counseling Requested:
 
D. If Business already exists, this section must be filled in where applicable:

Employees:
   Full Time   Part Time   Payroll:     Space/SF      Rent     Own

Gross Sales:

Export Sales:

Gov. Contracts:

Projections in 1 year:

No. Emp.
  

Sales
 

Payroll:
 

Space/SF      Rent     Own

SBDC Office Use Only

Financing Information: (Follow-up on Loan Approval)

Bank Source #1:

Amount:

Bank Source #2

Amount:

Owner's Equity:

Other Source:

Venture Capital:

Other:

Loan Type:

Jobs Created:

Jobs Retained:

If you want to clear this form and start over again hit the Reset Button  

I request business management counseling from the Small Business Development Center. I agree to cooperate should I be selected to participate in surveys designed to evaluate SBDC assistance services. I authorize the SBDC to furnish relevant information to the assigned management consultant(s), and I expect that information will be held in strict confidence by him/her.

I further understand that each consultant 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 consulting relationship in consideration of SBDC's furnishing management or technical assistance. I waive all claims against SBDC personnel, SCORE, SBA and its host organizations, SBI, and other SBDC Resource Counselors, arising from this assistance.

Authorized by: (Please type in your full name)
 

Today's Date:

When you have filled all the required boxes and completed this form "CLICK" on the submit button

You are now ready to move on to PART 2 of the SBDC Client Information Form. After you fill out the next few questions and submit your form you will be able to

To go to the second part of this form
"CLICK" on the STEP 2 button: 

©2008 The Ohio SBDC at Youngstown State University
 The Ohio SBDC at Youngstown State University
One University Plaza  •  Youngstown, OH  44555
275 Fifth Avenue • Youngstown, OH  44502
Office: 330.941.2140  •  Fax:330.941.2144