New Client Record
On-line Service Request Form Instructions:
  • Complete the on-line counseling form in its entirety
  • Indicate the nature of service and counseling you are requesting
  • Indicate if you wish us to call you to make an appointment to meet at our office or if you wish to correspond through e-mail. You can e-mail documents in Word or Excel for our review .
  • Complete the "I Accept" box (important)
  • Submit request
    •
    First Name
    		 MI
    		 Last Name
    E-mail
    		 Position
    		 No Mailings
    Business Name  (If Available)
    		 Bus. Phone
    		 Fax
    Mailing Address

    City
    Zip    		 Home Phone
    Business Status
    In Business Home Based    		 Start Date
    		 Are you any of the following?
    SBA Borrower
    SBA Applicant
    Surety Bonded
    COC Holder
    8(a) Certified
    MBE Certified
    Exporter
    Not Small Business
    AFDC
    TANF
    Handicapped
    Type of Industry

    Industry Title
    		 Business Organization
    Full Time Employees Part-time Employees
    How Long in Business years
    Business Description (e.g. Dress Shop etc.)

    Web site URL (If Available)
    Indicate briefly the nature of service and counseling you are seeking:
    		 Veteran Status

    Gender

    Race

    Hispanic
    How did you hear about our program?
    Word of mouth Bank   Newspaper   Chamb. of Com.   Internet   Radio  
    Television   Magazine   SBA   Other (please specify)

    Electronic Signature
    I request business management counseling from the Small Business Administration. I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA assistance services. I authorize SBA to furnish relevant information to the assigned management counselor(s) although I expect that this information to be held in strict confidence to the extent allowable by law. I further understand that any counselor 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 relationship;
    In consideration of SBA's furnishing management or technical assistance, I waive all claims against SBA personnel, SCORE, SBDC and its host organizations, SBI, and other SBA Resource Counselors arising from this assistance.
    I Accept Application Date and Time
    type "I Accept"

    If you are not satisfied with our services, please call the RCC Small Business Development Center at (541) 956-7494