Counseling Information Form

Counseling Information Form

Welcome to Ramapo College of New Jersey SBDC!
Contact Information

Email: sbdc@ramapo.edu

Phone: 201-684-7135

Operating Hours

Monday - Friday

8:30am - 5:00pm

Scheduled appointments only; No walk-ins
Part One: Client Information
Name*

First NameLast Name
Email*
example@example.com
Primary Phone Number*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
What is your business address?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Client Agreement: I request business counseling service from an SBA Resource Partner. I authorize SBA or its agents 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 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 SBA personnel and host organizations arising from this assistance. I understand that any information disclosed will be protected to the extent permitted by law.

Use of Information: The information in this form is to be provided by individuals and business seeking technical assistance services from SBA Resource Partners. The information is collected to help SBA’s continuing improvement of business counseling programs, to ensure effective oversight and management of entrepreneurial development programs and services, and to meet Congressional and Executive Branch reporting requirements. Resource Partners will submit information to SBA according to the terms of their notice of award.
Signature*

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Date*

MonthDayYear
Date
Participation in Surveys and SBA Communication: I agree to cooperate and be selected to participate in surveys designed to evaluate SBA Resource Partner services. I permit SBA or its agents the use of my name and address for SBA surveys and information mailings regarding SBA products and services.
Yes / No
Primary Counseling Subject
Race (mark one or more)
Ethnicity
Gender
Sexual Orientation
Do you consider yourself a person with a disability?
Military Status
Referred by
Part Two: Client Intake (to be completed by all clients)
Are you currently in business?

YesNo (STOP form is complete)Undetermined (STOP form is complete)
Company/Business Name:
Are you currently exporting
Type of Business (Choose primary category):
Business Ownership – What percentage of business is woman owned?
Conducting business online
8(a) Certified:
Of total employees, how many are engaged in the exporting aspect of your business?
For your most recent full business year, what was your Gross Revenues/Sales?
Amount of your Gross Revenues/Sales related to exporting?
Legal Entity:
Should be Empty:

Counseling Information Form

Part One: Client Information

Part Two: Client Intake (to be completed by all clients)