1. Type of Contact: Face to Face Online Telephone 2. Primary Counselor:
PART I: Client Intake:
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3. Date Company Established:
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4. Client Name (last, First, MI):
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5. Client Email:
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6.
Position:
Business Owner
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7. Client Work Phone:
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8. Client Home Phone:
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9. Client Fax Number:
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10. Client Cell Number:
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11. Client Address:
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12. Client
City:
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13. Client State:
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14. Client Zip Code:
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15. Zip +4:
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16. Client
County:
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17. Client Federal Representative District Number:
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18. Client State Representative District Number:
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19. Client State Senate District Number:
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20. Client Gender: Male Female
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21. Client Race:
Asian
Black or African American
Native American or Alaskan Native
Native Hawaiian or other Pacific Islander
White
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22. Client Ethnicity:
Hispanic Origin
Not of Hispanic Origin
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23.Client Veteran Status:
Non-Veteran
Service-Disabled Veteran
Veteran
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24. Client Reservist Status:
National Guard None
National Guard-Active Duty
Reservist
Reservist-Active Duty
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25. Disabled:
No
Yes
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PART II: Company Intake:
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26.
Company Name:
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27.
Company Email:
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28.
Company Website:
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29.
Company Phone #:
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30.
Company Fax #:
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31.
Company FEIN:
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32.
Company Cage Code:
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33.
Company DUNS #:
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34.
Total No. of Employees:
(Full
& Part Time)
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35.
Business Size: Large Other Small
Disadvantaged Small Certified SDB or SBA 8(a)
Minority-Owned Small Woman-Owned Small
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36.
Annual Sales: 2002
2003 2004
2005 Projected 2006
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37. Type of Business:(choose primary category) Surplus Dealer
Professional,
Scientific & Technical Services R & D
Mining Manufacturer/Producer Real
Estate & Rental & Leasing Management
of Companies & Enterprises
Utilities Finance
& Insurance Health
Care & Social Assistance
Agriculture,
Forestry, Fishing & Hunting
Information Wholesale
Dealer Accommodation
& Food Services Administrative
& Support
Construction Public
Administration Arts,
Entertainment & Recreation Waste
Management & Remediation Services
Retail
Dealer Educational
Services Transportation
& Warehousing Other
Services (except Public Administration)
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38. Miscellaneous:
International Trade
Home-based Business
Online Business
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39. What is the legal
entity of your business:
Sole Proprietorship Corporation LLC
S-Corporation Partnership
Other
(specify) _________________________
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40. Company Gender:
Male >50%
Female >
50%
Male/Female 50/50
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41.Company Veteran Status:
Non-Veteran
Service-Disabled Veteran
Veteran
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42. Company Address:
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43. Company City:
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44. Company State:
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45. Company Zip Code:
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46. Company County:
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47. Company Federal Representative
District Number:
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48. Company State Representative
District Number:
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49. Company State Senate District
Number:
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50. Is Business in a HUBZone:
No Located in HUBZone Only
Certified HUBZone? Date Certified _______
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51. Is Business Located in Distressed
Area:
No
Yes
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52. Keywords
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53. Product Service Codes (PSCs):
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54. Standard Industrial Classification SICs:
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55. North American Industrial Classification (NAICs):
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56. Product or service description:
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57. Signature Date:
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58. SBA
Client Type: 8(a) & Borrower 8(a) & Surety Bond 8(a) Client
Applicant
Borrower COC Procurement Assistance
Surety Bond None Technical Assistance
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59. State of Incorporation
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60 Referral From: Please Specify:
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61. Specific assistance requested:
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ANY CHANGES TO THIS FORM OR THE USE OF ANY OTHER INTAKE FORMS MUST HAVE PRIOR WRITTEN APPROVAL OF THE
SMALL BUSINESS DEVELOPMENT
CENTER STATE
DIRECTOR Updated
4/27/2006
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As a new client of the Illinois Small Business
Development Center
(SBDC), we'd like to advise you of certain rights and responsibilities you have
as one of our clients:
You have a right to expect:
·
prompt, courteous, and professional counseling services and to be
advised if the Illinois SBDC is unable to provide service within the time frame
required. Be aware that due to the demand for our services, cases must often be
prioritized by need and training may be recommended before counseling is
provided.
·
all information shared with the Illinois SBDC and any of its resources
(staff, faculty, volunteers, and consultants) will be held in strictest
confidence. No information provided by
you will be used to the commercial advantage of any staff member, consultant,
or other resource of the Illinois SBDC or to the benefit of any third party.
·
that your client status with the Illinois SBDC will remain
confidential. No public use of your
name, address, or business identity will be made without your prior approval.
Please note, however, that the Illinois SBDC is funded in part by the U.S.
Small Business Administration, Department of Commerce and Economic Opportunity
and the local host so, limited information with respect to your client status
is provided to those entities.
Our role is to counsel and assist
small business owners and those planning to go into business. We will not make business decisions or
judgments for you, though we will make recommendations and suggestions as
appropriate. These will be based upon
our best efforts to apply the experience and resources available to us to
assist you in making your own business decisions.
The Illinois SBDC may charge reasonable fees for
training programs, special services, and publications. However, you have a
right to feel secure that no fee will be charged by the ISBDC or its resources
for normal counseling services
provided to you. Also, no
recommendations will be made as to the purchase of goods or services from any
individual or firm with whom any I
