EICCD : Business : Request For Counseling Form

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Eastern Iowa Small Business Development Center, New Ventures Center, 331 West 3rd Street, Suite 100, Davenport, Iowa 52801, Phone: (563) 336-3401, Fax: (563) 336-3479


Request For Counseling Form

PART I: Client Request for Counseling

All fields are required.
1)  Client Name  (Name of the person completing the form/representative of the business)
3)  Telephone  (include area code)
9)  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. Please note: The estimated burden for completing this form is 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.
10)  Preferred Date & Time For Appointment  (example 01-23-2006 and 10:00am)
11)  Client Signature
         NOTE:  Checking the "Signature" box below and submitting this application is
         considered the same as a written signature.

PART II: Client Intake  (to be completed by all Clients)

12)  Race  (mark one or more):
13)  Ethnicity:
14)  Gender:
15)  Do you consider yourself a person with a disability?          
16)  Veteran Status:
16a)  Military Status:
17)  What inspired you to contact us?  (mark all that apply):
18)  Is the client currently in business?          
20)  Type of Business  (choose primary category):
21)  Business Ownership - What percentage of your business is male or female ownership?
23)  Do you conduct business online?          
24)  Is this a home based business?          
25)  Total No. of Employees  (full & part time):
26)  For your most recent full business year, what were your:
27)  What is the legal entity of your business?
28)  What is the nature of counseling you are seeking?  (choose primary category):
Please NOTE:
Clients are responsible for scheduling all appointments. The Eastern Iowa SBDC will not follow-up on form submissions unless you contact us first.
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