1. Your Name (First, Middle, Last)

3. Email       		2. Telephone Numbers(s)

Home Telephone           
Work -Telephone            
Fax Number                    
4. Address

5. City

6.County

7. State  

 8.Zip
9. Race 10. Ethnicity


11. Business Owner Gender

12. Within the last two years, have you ever received:
a. Aid to Families with Dependent Children (ADFC)
yes no
b. Temporary Assistance to Needy Families
yes no

13. Veteran Status

 
14. How did you hear of us?
a. Word of Mouth
b. Bank             
c. Newspaper      		d. Chamber of Commerce
e. Internet                      
f. Radio                          		g. Television    
h. Magazine    
i. Other            		j. SBA           
15. Describe the nature of counseling you are seeking.
16. Currently in Business? yes no Is this a Home-based Business? yes no
17. Type of Business?
18. Name of Company? 19. How long in Business? 
20. Indicate preferred date and time of appointment:
Date:		 Time:
I request business management counseling from the Small Business Administration. I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA assistance services. I authorize SBA to furnish relevant information to the assigned management counselor(s) although I expect that information to be held in strictest confidence by him/her.
I further understand that any counselor has agreed 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 SBA's furnishing management or technical assistance, I waive all claims against SBA personnel, SCORE, SBDC and its host organizations, and other SBA resource counselors arising from this assistance.
PLEASE NOTE: The estimated burden hours for the completion of this form is 7 minutes per response. If you have any questions or comments concerning this estimate or any other aspect of this information collection, please contact: Chief Administrative Information Branch, U.S. Small Business Administration, Washington, D.C. 20416 and Gary Waxman, Clearance Office, Paperwork Reduction Project (3245-0096), Office of Management and Budget, Washington, D.C. 20503.
Signature: (print Name for signature)
 Date:

 

    SCORE Form 641 Request for Counseling

 

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Please fill in or check all applicable boxes.  A copy of the completed form will be electronically transmitted to a SCORE
official who will process your request. You can use your browser print function to print a copy of this Application.