North Texas Small Business Development Centers (SBDC) Client Intake Form "*" indicates required fields CLIENT NAME (Last, First, M)* EMAIL* Position* Owner/Sole Proprietorship Employee President Vice-President Partner Other Position (Other) WORK PHONE*CELL PHONE*HOME PHONEFAXMAILING ADDRESS* Street Address City State / Province / Region ZIP / Postal Code GENDER* Male Female RACE (mark one or more)* Asian Native Hawaiian or Pacific Island Black or African American Native American or Alaska Native White ETHNICITY Non-Hispanic Hispanic VETERAN STATUS* Non-Veteran Service-Disabled Vietnam Veteran RESERVIST STATUS* None National Guard National Guard- active duty Reservist Reservist- active duty DO YOU HAVE A DISABILITY?* Yes No CURRENTLY IN BUSINESS?* Yes No COMPANY INFORMATIONONLY COMPLETE THIS SECTION IF YOU HAVE A BUSINESS CURRENTLY IN OPERATION. (The CURRENTLY IN BUSINESS selection above is set to 'Yes')Established date of business MM slash DD slash YYYY If IN BUSINESS, but you want to explore a new business, Please specify the area of interest: Are you currently EXPORTING? Yes No Not yet but interested Export Countries:* Since you selected 'Yes' above, Please indicate current export countries here. COMPANY NAME Provide a company name if in business or have a new name for a start-up.WEBSITE PHYSICAL ADDRESS OF BUSINESS Street Address City State / Province / Region ZIP / Postal Code BUSINESS OWNERSHIP Male Female Male/Female owners BUSINESS SIZE Disadvantaged - Small Large Minority Owned - Small Other Small BUSINESS LEGAL ENTITY Sole Proprietorship Partnership S-Corporation LLC Corporation HOME-BASED? Yes No DO YOU CONDUCT BUSINESS ONLINE? Yes No 8(A) Certified Yes No SBA RELATIONSHIP Applicant Borrower COC Procurement Assistance Technical Assistance TYPE OF BUSINESS Manufacturing Wholesale Construction Retail Services Other Type of Business (Other) PRODUCTS/SERVICES: NAICS CODE(S): (ONLY IF IN BUSINESS) SBDC staff can assist with NAICS code for your business)WHAT ARE YOUR TOTAL NUMBER OF EMPLOYEES?Full Time EmployeesPart Time EmployeesHow many employees are engaged in the exporting aspect of the business?Since you indicated that you are currently exporting, please provide the number of employees engaged in export aspects.FOR THE MOST RECENT FULL BUSINESS YEAR, PLEASE PROVIDE:Gross Revenue/Sales (GRS)+Profits/-LossesWHAT PROMPTED YOU TO CONTACT US (REFERRED FROM) Advertising/Marketing Chamber of Commerece Client/Word of Mouth College/University Email Media/TV/Radio Lender/Banker Local EDC News Oulet SBA Network SBDC Training Event Website Social media Other Referred Other Please let us know how you were referred since you selected 'other' above.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.* Yes No Client Signature*Today's date* MM slash DD slash YYYY 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*Today's Date* MM slash DD slash YYYY DateAfter 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!
