U.S. SBA 641

Counseling Information Form

First Name *

Middle Name *

Last Name *

Email *

Phone *

Address *

I confirm that I want to receive content from this company using any contact information I provide.

Contact Type (Specific) *

Language Preference *

English

Spanish

Race *

Ethnicity *

Gender *

Sexual Orientation *

Do you consider yourself a person with a disability? *

Yes

Prefer Not to Say

Military Status *

Branch of Service *

Referred by? (mark all that apply) *

Business Industry *

Stage of Business *

Exploring

Startup

Existing

In Business? *

Yes

Currently Exporting (sba) *

Yes

Name of Business

Business Address

Date Business Started (MM/YYYY)

Are you a home based business?

Yes

Are you 8a certified?

Yes

Full Time Employees:

Part Time Employees:

1099 Contractors:

Do you conduct business online?

Yes

+Profits/ -Losses

Amount of gross revenues/sales related to exporting (sba)

Gross Revenue/Sales $ (recent full business year)

Nature of Counseling: *

Type of Meeting? *

Face to Face

Online (Virtual)

Telephone

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 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. Use of Information: The information in this form is to be provided by individuals and businesses seeking technical assistance services from the Small Business Administration (SBA) or an SBA Resource Partner. The information is collected to help SBA's continuing improvement of business counseling programs, to ensure effective oversight and management of entrepreneurial development programs and grants, and to meet Congressional and Executive Branch reporting requirements. The form should be submitted at the site of service to the counselor providing the service. Resource Partners will submit information to SBA according to the terms of their notice of award. *

Yes

CEED Business Center Intake Form

Last Years Household Income *

Number of people in your household? *

Will you be applying for a small business loan? *

Yes

What is your Credit Score? *

Are you involved in any lawsuit at this time or have you ever filed for personal or business bankruptcy protection? *

Yes

If Yes, furnish details here-lawsuit-business-bankruptcy

Which of the natural disasters affected your business? (if neither, don't select anything)

Covid-19

Hurricane

What is the estimated cost to start your business? (if not known, please give an approximate amount) *

Who is your target market? *

Which type of business industry are you interested in? *

Which of the following loans have you applied and received money from?

What is the total amount of funding you received in any of the above loans? (if none, enter 0) *

For Food Based Businesses: Do you have a certified kitchen?

Yes

For Food Based Businesses: Do you have a commissary?

Yes

Duns#

NAICS

Which certifications do you possess? (if neither, don't select anything)

HUB (Historically Underutilized Businesses)

DBE (Disadvantaged Business Enterprises)

DOT (Department of Transportation) for Drivers

How did you hear about CEED? *

Who is your City Council Member? (if unknown, type unknown) *

Who is your County Commissioner? (if unknown, type unknown) *

Who prepares your Payroll? (if not applicable, type "N/A") *

Are you interested in speaking with a Payroll/HR Specialist? *

Yes

Are you ready for tax season? *

Yes

Media Release Form

I grant permission to CEED to use my information, photographs and/or video for use in publications including videos, email blasts, recruiting brochures, newsletters, and magazines and to use my image in electronic versions of the same publications or on the CEED website or other electronic forms of media. I have read this release before signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms on this release.

Yes

Intake Form Completion

Signature *

Clear