Get the legal form you need right now

Request for Counseling (United States)

This is a Small Business Administration (SBA) request for counseling. The form provided here is simply a sample of what the actual Form 641 looks like.

OMB Approval No. 3245-0091

Case Number: _____________________________

U.S. Small Business Administration
Request for Counseling

1. Your Name (First, Middle, Last) _____________________________

2. Telephone Number(s)

Home _____________________________

Business _____________________________

Fax _____________________________

3. Email address _____________________________

4. Street Address _____________________________

5. City _____________________________

6. County _____________________________

7. State _____________________________

8. Zip _____________________________

9. Race (mark one or more)

a. Native American or Alaskan Native ____
b. Asian ____
c. Black or African American ____
d. Native Hawaiian or other Pacific Islander ____
3. White ____

10. Ethnicity

a. Hispanic Origin ____
b. Not of Hispanic Origin ____

11. Business Owner Gender

a. Male ____
b. Female _____
c. Male/Female ____

12. Within the last two years, have
you ever received:

a. Aid to Families with Dependent
Children (AFDC)

____ Yes ____ No

b. Temporary Assistance to Needy
Families (TANF)

____ Yes ____ No

13. Veteran Status

a. Veteran ____
b. Service Connected Disabled Veteran ____
c. Disabled Veteran ____
d. Non-veteran _____

14. How did you hear of us?

a. Word of Mouth ____
b. Bank ____
c. Newspapers ____
d. Chamber of Commerce ____
e. Internet ____
f. Radio ____
g. Television ____
h. Magazine ____
i. Other _____________________________
j. SBA ____

15. Describe the nature of the counseling you are seeking. _____________________________

16. Currently in Business? ____ Yes ____ No (If no, skip to line 20)

Is this a Home-based Business? ____ Yes ____ No

17. Type of Business _____________________________

18. Name of Company: _____________________________

19. How long in business? _____________________________

20. Indicate preferred date & time for appointment:

Date: _____________________________ Time: _________________

I request business management counseling service from a Small Business Administration Resource Partner. 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). I understand that any information disclosed to be held in strict confidence by him/her.

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 counseling relationship. In consideration of the counselor(s) furnishing management or technical assistance, I waive all claims against SBA personnel, SCORE and its host organizations, and other SBA Resource Counselors arising from this assistance.

Please note: The estimated burden for completing this form is 15 minutes per response. You will not be required to respond to this information collection if a valid OMB approval number is not displayed. If you have questions or comments concerning this estimate or other aspects of this information, please contact the U.S. Small Business Administration, Chief, Administrative Information Branch, Washington, DC 20416 and/or Office of Management and Budget, Clearance Officer, Paperwork Reduction Project (3245-0091), Washington, DC 20503.

Signature: _____________________________

Date: _____________________________


U.S. Small Business Administration
Counseling Information Sheet


Chapter Number _____________________________

Branch Name _____________________________

Telephone Counseling ____

E-mail Counseling ____

Case Number _____________________________

Date Entered _____________________________

Entry by _____________________________


1. Client Information:

Name:
First _____________________________

Middle _____________________________

Last _____________________________

2. Appointment Scheduled:

With (counselor) _____________________________

On (date) _____________________________

(time) _____________________________ AM / PM

Conf. By _____________________________ on _____________________________

3. a) New case ____ b) Follow-on ____ c) Close out ____

4. Legal Entity:

___ Sole
___ Proprietorship
___ Partnership
___ Corporation
___ S-Corporation
___ LLC

5. Client objective / Counseling purpose: _____________________________

6. Primary area(s) of counseling:

a. Start-ups ____
b. Capital Sources ____
c. Marketing/Sales ____
d. Financial ____
e. Human Resources ____
f. Technology ____
g. Intl. Trade ____
h. Business Plan ____
i. Buy/Sell ____
j. Franchises ____
k. Other _____________________________
l. Other _____________________________

7. Counselor's Notes:

_____________________________

_____________________________

8. Counselor Name(s) _____________________________

9. Counseling Date _____________________________

10. Counseling Hours _____________________________

11. SBA Client:

a) Borrower ____
b) Applicant ____
c) 8(a) Client ____
d) COC ____
e) Surety Bond ____

12. Has client been informed about other SBA resources? ____ Yes ____ No

Legal Forms Categories

Recently Added Forms

Library Of Legal Forms