U.S. Small Business Adminstration Counselling Information Form OMB Approval No.: 3245-0324 Expiration Date: 09/30/2006 Client Number: Location Code: Initials of Data Encoder: . 1. Name of the office providing the service: 2. City/State of office location: 1a. Type of Client: Face to Face Online Telephone PART I: Client Request for Counseling 3. Client Name (Name of the person completing the form/representative of the business) Last: First: M.I: 4. Email: 5. Telephone Primary: Secondary: 6. Fax: 7. Street Address/PO Box (give business address if currently in business) 8. City 9. State 10. Zip +4 11. 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. 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. Please note: The estimated burden for completing this form is three (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. 12. Preferred date & time for appointment Date: Time: 13. Client Signature Date . PART II: Client Intake (to be completed by all Clients) 14. Race (mark one or more) Asian Native American or Alaska Native Native Hawaiian or Other Pacific Islander White Black or African American 15. Ethnicity Hispanic Origin Not of Hispanic Origin 16. Gender Male Female   17. Do you consider yourself a person with a disability? Yes   No 18. Veteran Status Non-Veteran Serv