Tyler Junior College SBDC - Request Counseling Form

Tyler SBDC: Request Counseling Form

				Sponsored by The U.S. Small Business Administration Real Help in the Real World.

Counseling Form

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Company Name:

(if in business)

First Name:

M.I.

Last Name:

Business Owner?

Yes No

Email Address:

Web Site Address:

Telephone:

Fax:

Business Size:

Disadvantaged Small

Disadvantaged SBA 8A Small

Woman-Owned Small

Minority Owned Small

Other Small

Large

Business Type(s):

Manufacturing/Producer

Service Establishment

Retail Dealer

Wholesale Dealer

Construction

Research/Development

Surplus Dealer

Not in Business

Organization Type:

Sole Proprietorship (Individual)

Partnership

Corporation

Limited Liability

Sub S Corporation

Gender:

Female (51% woman-owned)

Male

Male and Female (Partnership)

Home Based Business?

Yes

No

Address:

City:

State:

Zip Code: -

Business Start Date:

(e.g. 1-1-2001)

Ethnic Group:

Native American or Alaskan Native

Asian

Native Hawaiian or Pacific Islander

Black or African American

White

Hispanic?

Yes

No

Do you engage in
International Trade?

Yes

No

Military Status:

Non-Veteran Veteran

Veteran

Vietnam-Era Veteran

Disabled Veteran

Disabled Vietnam Veteran

Disabled?

Yes

No

SBA Client Type:

None

Borrower

Applicant

COC

8a Client

8a Borrower

8a Surety Bond

Surety Bond

Business Status:

Pre venture

In Business

Referral Form:

Accountant

(Select one only)

Advertising/Marketing

Bank

Chamber

Client/Word-of-Mouth

College/University

Government Agency

Faculty

Legal Counselor

Local EDC

Media-TV/Radio

Network Agency

Newspapers

PTA Program

SBA

SBDC

SCORE

Training Seminar

Yellow Pages

If in Business:

Sales:

Number of Employees:

Welfare to Work:

I have received Aid to Families with Dependent Children. (AFDC)

I have received Temporary Assistance for Needy Families. (TANF)

APPLICANT MUST SIGN AND DATE

I request business management assistance from the North Texas SBDC. I agree to cooperate should I be selected to participate in surveys designed to evaluate the North Texas SBDC’s services. I authorize the Small Business Development Center to furnish relevant information to the assigned management counselor(s), although I expect that information to beheld in strict confidence by him/her. I further understand that all counselors have agreed not to: (1) recommend goods or services from sources in which they have an interest, and (2) accept fees or commissions developing from this counseling relationship.

By my signature below, and in consideration of the center furnishing of management or technical assistance, I waive all claims against the center’s personnel and its host organization. I understand that there are no warranties or assurances in connection with the counseling assistance.

Applicant Name:

Date: (e.g. 12-10-2001)

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Last modified: May 29, 2005

Tyler Junior College gives equal consideration to all applicants for admission, employment and participation in its programs and activities without regard to race, creed, color, national origin, gender, age, marital status, disability or veteran status.

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