Required entries *

1.    Name of the Office Providing the Service Score Chapter 19

2.    City/State of Office Location Kansas City MO

Part I: Client Request for Counseling

3.    Your Name (Last, First, MI)    * 

4.    Email Address   

5.    Telephone Number(s)

       Primary     *

       Secondary  

6.    Fax  

7.  Street Address/PO Box   *

8.  City   *

9.  State   *

10. Zipcode   *

11.  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 (Yes No). I understand that any information disclosed will be held in strict confidence. (SBA will not provide your personal information to commercial entities).  I further understand that the counselor(s) 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 counselor(s) 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.

12.  Appointment time/place:  As agreed between client and counselor

13.  I understand that by submitting this form, I accept all conditions of this request

    Yes 

    No 

Part II: Client Input (to be completed by all Clients)

14. Race (mark one or more)

    Native American or Alaskan Native

    Asian

    Black or African American

    Native Hawaiian or other Pacific Islander

    White

15. Ethnicity

    Hispanic Origin

    Not of Hispanic Origin

16. Your Gender 

        Male  

        Female  

17. Do you consider yourself a person with a disability?

    Yes

        No

18. Veteran Status Non-Veteran Veteran Service-Disabled Veteran

18a. Military Status Member of Reserve or National Guard On Active Duty

19. What inspired you to contact us? (mark all that apply)

Other (Please describe) 

20. Are you currently in business? (If No then skip to 30)

        Yes

        No

21. Name of Company

22.  Type of Business (Choose Primary Category) 

       Mining Utilities Information Construction Retail Trade Manufacturing Finance and Insurance Wholesale Trade Public Administration Educational Services Real Estate & Rental & Leasing Healthcare & Social Services Accommodation & Food Services Arts, Entertainment & Recreation Transportation & Warehousing Professional, Scientific & Technical Services Management of Companies & Enterprises Agriculture, Forestry & Hunting Admistrative & Support Waste Management & Remediation Services Other Services (except Public Administration)

23.  Business Ownership - What percentage of your business is male or female ownership?

        % Male

        % Female

24. Month and Year Business Started  

25.  Do you conduct business online?

            Yes

            No

26.  Is this a home based business?

            Yes

            No

27.  Total number of employees (full and part time)  

28.  For your most recent full business year, what were your:

          Gross Revenues/Sales ($)

          + Profits/- Losses ($)

29.  What is the legal entity of your business? Sole Proprietorship Corporation LLC S-Corporation Partnership Other (Specify)    

       Other (Please describe) 

30.  What is the nature of the counseling you are seeking?

       Startup Assistance (How do I start a small business?) Business Plan Financing/Capital (such as applying for a loan, building equity capital) Managing a Business Human Resources/Managing Employees Customer Relations Business Accounting/Budget Cash Flow Management Tax Planning Marketing/Sales (promotion, market research, pricing, etc.) Government Contracting (including certifications) Franchising Buy/Sell Business Technology/Computers eCommerce (using the Internet to do business) Legal Issues (such as, Should I incorporate?) Services International Trade

30a. Describe specific assistance requested in space below: