SCORE Form 641 - Request for Counseling

SCORE^® Request for Counseling

Note: * = Required Field

*1) Name:

First: * MI: Last Name: *

*2) Address:

*City: *State: *Zip Code: Zip4:

3) E-Mail:

*4) Phone:

*Primary: Secondary: Fax:

Enter phone numbers formatted as 999-999-9999

5) Race:

6) Ethnicity:

7) Gender:

Female Male

8) Do you consider yourself as someone with a disability? Yes No

9) Veteran Status:

10) Military Status:

11) What inspired you to contact us (select all that apply)?

Bank
Business Owner
Chamber of Commerce
Educational Institution
Internet
Local Economic Development Official
Magazine

Minnesota Secretary of State Office
Newspaper
Other SCORE Client
SBA
Television/Radio
Word of Mouth
Other - specify:

*12) Are you currently in business? (if no, skip to #22) Yes No

13) Name of Company:

14) Type of Business (choose primary):

15) What percentage of your business is male or female owned? % Male % Female

16) Date the business was started (MM/YYYY) - Month: / Year:

17) Do you conduct business on-line? Yes No

18) Is this a home based business? Yes No

19) Number of employees (Full and Part Time)?

20) For your most recent full business year, what were your:

Use Whole Numbers Only

Gross Revenue/Sales: Profits/-Losses:

21) What is the legal entity of your company?

Corporation
LLC
Partnership
S-Corporation
Sole Proprietorship
Other (Specify)

*22) What is the nature of the counseling you are seeking (choose primary category)?:

Other:

*23) Describe the specific assistance requested:

Please be as detailed and specific as possible so that we can assign the best available counselor.

*24) Which Minnesota SCORE Chapter is most convenient for your counseling session?

NOTE: Only select a specific chapter if you wish to override the automatic routing to the chapter or branch serving your zip code.

Auto Assignment by Zip Code - *** Strongly Recommended ***
Minneapolis - Chapter #2
New Ulm - Chapter #654
Red Wing - Chapter#668
Rochester - Chapter #406
St. Cloud - Chapter #468
St. Paul - Chapter #391
South Metro (Burnsville) - Chapter #628

*25) Agreement:

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 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 authorize SBA 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 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.

By submitting this form, you agree to the preceding disclaimer.

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SBA Form 641 Substitute.

SCORE® Request for Counseling

SCORE^® Request for Counseling