Pacific Islands Small Business Development Center Network - For all your business counseling and training needs

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Conferences

GUAM SBDC - How to Market Your Business (5/9)
GUAM SBDC"Double Entry Bookkeeping using Quickbooks (Part II of II)" (5/10)
GUAM SBDC - How to Market Your Business (5/16)
GUAM SBDC - Introduction to Financial Statements – The Basics (Part 1) (5/23)
GUAM SBDC - Introduction to Financial Statements: Financial Statement Analysis (Part 2) (5/30)

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REQEST FOR COUNSELING – SBA FORM 641

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The University of Guam–College of Professional Studies–Pacific Islands Small Business Development Center Network is sponsored by the U.S. Small Business Administration under a Cooperative Agreement. This Cooperative Agreement is partially funded by U.S. Small Business Administration. SBA’s funding is not an endorsement of any products, opinions, or services. All SBA funded programs are extended to the public on a nondiscriminatory basis.

PART 1: CLIENT REQUEST FOR COUNSELING

1. Name: (person completing form or business representative)		Required
2. Email:		Required
3. Telephone:
	Primary:
	Secondary:
	Mobile:
4. Fax:

5. Street Address / P.O. Box




		Regional Office:

6. APPLICANT MUST READ, SIGN & DATE I request business management assistance from the Guam SBDC a service center of the Pacific Islands SBDC Network (PISBDCN). I agree to cooperate should I be selected to participate in surveys designed to evaluate the center’s services. I authorize the center to furnish relevant information to the assigned management counselor(s), although I expect that information to be held in strict confidence by him/her. I further understand that all 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. By my signature below, and in consideration of the center’s furnishing management or technical assistance, I waive all claims against PISBDCN personnel and its host organization(s). I understand that there are no warranties or assurances in connection with the counseling assistance. I Agree

PART 2: CLIENT INTAKE

(To be completed by all Clients)

8. Race	9. Ethnicity
Asian Black - African American Caucasian Native American or Alaskan Native Native Hawaiian or other Pacific Islander Other:	Hispanic Origin Not of Hispanic Origin

10. Gender:	11. Do you consider yourself a person with a disability?
Male Female	Yes No

12. Veteran Status:	13. Military Status:
Veteran Service Disabled Veteran Non-veteran	Reserve or National Guard On Active Duty None

14. What inspired you to contact us? (mark all that apply):
SBA Bank Business Owner Television/Radio Other Client Magazine	Internet Newspaper Chamber of Commerce Educational Institution Local Economic Development Official Word of Mouth
Other (specify):

15. Are you currently in business?
Yes No (if no, skip to #25)

16. Name of company:

17. Type of Business:
Mining Utilities Information Construction Retail Trade Manufacturing Finance/Insurance Wholesale Trade Public Administration Educational Services	Real Estate/Rental/Leasing Health Care/Social Assistance Accommodation/Food Service Arts/Entertainment/Recreation Transportation/Warehousing Professional/Scientific/Technical Service Management of Companies/Enterprises Agriculture/Forestry/Fishing/Hunting Administrative & Support Waste Management/Remediation Service
Other Services (except Public Administration)

18. Business Ownership: What percentage of your business is male or female ownership?
% Male

% Female

19. Month & Year Started:	20. Do you conduct business online?
	Yes No

21. Is this a home-based business?	22. Total Number of Employees:
Yes No	full-time

	part-time

23. For the most recent full business year, what were your:
Gross Revenue/Sales:	$

+Profits/-Losses:	$

24. What is the legal entity of your business?:
Sole Proprietorship Corporation LLC	S-Corporation Partnership
Other (specify)

25. What is the nature of counseling you are seeking? (choose primary category)
Business start-up Business plan Financing/Capital Managing a business Human resource/managing employees Customer Relations Business Accounting/Budgeting Cash Flow Management Tax Planning	Marketing/Sales Government Contracting/Certification Franchising Buy/Sell Business Technology/Computers eCommerce Legal Issues International Trade

Briefly describe specific assistance you are requesting:

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