CORE NTSBDC Client Intake Form 641

North Texas Small Business Development Centers SBDC Client Intake Form
CLIENT NAME (Last, First, M)*
EMAIL
example@example.com
Position*

Owner/Sole ProprietorshipEmployeePresidentVice-PresidentPartnerOther
WORK PHONE*
CELL PHONE*
HOME PHONE
FAX
MAILING ADDRESS*

STREET ADDRESS

Street Address Line 2

CITYSTATE

ZIP CODE
GENDER*

MaleFemale
RACE (mark one or more)*

AsianNative Hawaiian or Pacific IslandBlack or African AmericanNative American or Alaska NativeWhite
ETHNICITY

Non-HispanicHispanic
VETERAN STATUS*

Non-VeteranService-DisabledVietnam Veteran
RESERVIST STATUS*

NoneNational GuardNational Guard- active dutyReservistReservist- active duty
DO YOU HAVE A DISABILITY?*

YesNo
CURRENTLY IN BUSINESS?*

YesNo
COMPANY INFORMATION

ONLY COMPLETE THIS SECTION IF YOU HAVE A BUSINESS CURRENTLY IN OPERATION.
Established date of business (ONLY IF YOU ARE IN BUSINESS)

MonthDayYear
Date
If IN BUSINESS, but you want to explore a new business, Please specify the area of interest:
If IN BUSINESS, are you currently EXPORTING?

YesNoNot yet but interested
If YES, Please indicate the Countries below.
Export Countries:
COMPANY NAME (ONLY IF IN BUSINESS OR HAVE A NAME FOR START-UP)
WEBSITE
PHYSICAL ADDRESS OF BUSINESS

STREET ADDRESS

Street Address Line 2

CITYState / Province

Postal / Zip Code
WHAT PROMPTED YOU TO CONTACT US (REFERRED FROM)

Advertising/MarketingChamber of CommereceClient/Word of MouthCollege/UniversityEmailMedia/TV/RadioLender/BankerLocal EDCNews OuletSBA NetworkSBDCTraining EventWebsiteSocial mediaOther
BUSINESS OWNERSHIP (ONLY IF IN BUSINESS)

MaleFemaleMale/Female owners
BUSINESS SIZE (ONLY IF IN BUSINESS)

Disadvantaged - SmallLargeMinority Owned - SmallOther Small
BUSINESS LEGAL ENTITY (ONLY IF IN BUSINESS)

Sole ProprietorshipPartnershipS-CorporationLLCCorporation
HOME-BASED? (ONLY IF IN BUSINESS)

YesNo
DO YOU CONDUCT BUSINESS ONLINE? (ONLY IF IN BUSINESS)

YesNo
8(A) Certified (ONLY IF IN BUSINESS)

YesNo
SBA RELATIONSHIP (ONLY IF IN BUSINESS)

ApplicantBorrowerCOCProcurement AssistanceTechnical Assistance
TYPE OF BUSINESS (ONLY IF IN BUSINESS)

ManufacturingWholesaleConstructionRetailServicesOther
PRODUCTS/SERVICES: (ONLY IF IN BUSINESS)
NAICS CODE(S): (ONLY IF IN BUSINESS)
SBDC staff can assist with NAICS code for your business)
WHAT ARE YOUR TOTAL NUMBER OF EMPLOYEES? (ONLY IF IN BUSINESS)
Full Time (ONLY IF IN BUSINESS)
Part Time (ONLY IF IN BUSINESS)
How employees are engaged in the exporting aspect of the business?
FOR THE MOST RECENT FULL BUSINESS YEAR, PLEASE PROVIDE:
Gross Revenue/Sales (GRS)
DISCLOSURE: I request business-counseling service from the Small Business Administration SBA or an SBA Resource Partner. I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA services. I permit SBA or its agent the use of my name and address for SBA surveys and information mailings regarding SBA products and services. I understand that any information disclosed will be held in strict confidence. SBA will not provide your personal information to commercial entities I authorize SBA to furnish relevant information to the assigned management counselors I further understand that the counselors 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 counselors furnishing management or technical Assistance, I waive all claims against SBA personnel, and that of its Resource Partners and host organizations, arising from this Assistance. Please note: The estimated burden for completing this form is 3 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: U.S. Small Business Administration, 409 3rd Street, SW, Washington, DC 20416, and to: Desk Officer SBA, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C., 20503. OMB Approval 3245-0324 PLEASE DO NOT SEND FORMS TO OMB. SBDC services are not available to individuals or entities that have been debarred or suspended by the federal government. By agreeing to receive assistance from the SBDC with your signature on this form, you are self-certifying that you are not currently federally debarred or suspended and also agree to cease using SBDC services if you become federally debarred or suspended in the future.
I permit SBA or its agent the use of my name and address for SBA surveys and information mailings regarding SBA products and services.*

YesNo
Client Signature*

Clear
Today's date*

MonthDayYear
North Texas SBDC Revised SBA Form 641Previous Editions are Obsolete Revision 1 -- 2015-2016
North Texas Small Business Development Center Network Business Advising Client Engagement Agreement
The North Texas Small Business Development Centers Network provides expert management and technical assistance to start-up and existing businesses throughout 49-counties in the North Central Texas Region. The management and technical assistance consist of one-on-one advising to address the needs of your existing business or to aid you in starting a business.
PERIODIC SURVEYS MEASURING PROGRAM OUTCOMES
SBDC counseling services are provided at no fee to you. We will request you to complete surveys to measure satisfaction and economic impact. The surveys are designed to gather business information that supports the no-fee counseling infrastructure provided to you. Upon receiving the surveys, please remember your experience and the assistance you received from one or more of the North Texas SBDC field centers. The business data you provide will help us to identify needs and ensure we continue to provide relevant and effective small business counseling and training. The data collected will be compiled and converted to summary data without identifying specific businesses. You will not be identified individually nor will your information be conveyed to third parties.
EXPECTATIONS WITH YOUR BUSINESS CONSULTANT
Your advisor will review your business plan and determine a course of action for your business. Both you and your advisor will identify areas of management assistance and a plan of action for the next steps. Thank you for becoming a customer of the North Texas SBDC Network and we look forward to assisting your business needs at every stage of your business growth. We want to contribute to your success for many years to come!
Client Signature*

Clear
Today's Date*

MonthDayYear
Date
After completing this document you will be eligible for an appointment with one of our advisors. Your assigned advisor will review this document and sign the "North Texas Small Business Development Center Network Business Advising Client Engagement Agreement" in your initial advising meeting. Any questions or concerns call Tarrant Small Business Development @ 817-515-2600!
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North Texas Small Business Development Centers SBDC Client Intake Form

COMPANY INFORMATION

North Texas Small Business Development Center Network Business Advising Client Engagement Agreement