Wharton Small Business Development Center

COURSES

REGISTRATION

U.S. Small Business Administration Request for Counseling

Before attending one of our Strategic Project Workshops we ask that you complete the following form. Thank you for your cooperation.

(**Required Information)

1.)

Your Name

**First

Middle Initial

**Last

2.)

Telephone Number(s)

Please provide a home or business phone number so we can contact you to schedule a meeting.

Home

Business

Fax

3.)

**Email Address

4.)

**Street Address

5.)

**City

6.)

County

7.)

**State

8.)

**Zip + 4 ( Need Help? )

9.)

**Race (Mark one or more)

	a. Asian
	b. Black or African American
	c. Native American or Alaskan Native
	d. Native Hawaiian or other Pacific Islander
	e. White / Caucasian
	f. Choose not to respond

10.)

**Ethnicity

	a. Hispanic Origin
	b. Not of Hispanic Origin
	c. Choose not to respond

11.)

**Business Owner Gender

	a. Female
	b. Male
	c. Male/Female Partnership

**Your Gender

	a. Female
	b. Male

12.)

**Do you consider yourself a person with a disability?

	Yes
	No
	c. Choose not to respond

13.)

**Veteran Status

	a. Veteran
	b. Service-Disabled Veteran
	c. Non-Veteran
	d. Choose not to respond

14.)

**Reservist Status

	a. National Guard
	b. National Guard - Active Duty
	c. Reservist
	d. Reservist - Active Duty
	e. None
	f. Choose not to respond

15.)

How did you hear of us?

	a. Word of Mouth		b. Bank
	c. Newspapers		d. Chamber of Commerce
	e. Internet		f. Radio
	g. Television		h. Magazine
	i. SBA		j. Other

16.)

How can the Wharton SBDC assist you?
(Select all that apply)

	Accounting		Business Plan
	Business Sales / Liquidation		Computer Systems
	Engineering / Technology		Financial Analysis / Cost Control
	Government Procurement		International Trade
	Inventory Control / Purchasing		Loan Application
	Marketing / Sales		Personnel Management
	Product Development		Sources of Financing
	Startup / Acquisition

17.)

Describe the nature of the counseling you are seeking. List the issue(s) you feel most important.

18.)

What business challenge or opportunity led you to contact the Wharton SBDC?

19.)

**Status:

(All three questions are required)

Currently in Business:

Yes - (If selected, fill in line 22)

Is your business generating revenue?

Yes

If yes, please estimate your revenue for the past 12 months.

Do you have a business plan?

Yes

If you answered YES, you will need to provide a written draft of the business plan to the Wharton SBDC prior to meeting with a consultant. To find out more information about what constitutes a business plan, please Click Here and you will be directed to the SBA's website. You can email your business plan to sbdc_mail@wharton.upenn.edu, fax it to 215.898.1063 or mail it to Wharton Small Business Development Center, Vance Hall Suite 112, 3733 Spruce Street, Philadelphia, PA 19104

20.)

Briefly Describe your product/service:

21.)

**Name of Business

22.)

Date Established

I request business management counseling service from a Small Business Administration Resource Partner. 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). I understand that any information disclosed is to be held in strict 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 the counselor(s) furnishing management or technical assistance, I waive all claims against SBA personnel, SCORE and its host organizations, and other SBA Resource Counselors arising from this assistance.

Please Note: The estimated burden for completing this form is 15 minutes per response. 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, Chief, AIB 409 3rd St., S.W., Washington, D.C. 20416 and Desk Officer for the Small Business Administration, Office of Management and Budge, New Executive Office Building, Room10202, Washington, D.C. 20503. OMB Approval (3245-0091) PLEASE DO NOT SEND FORMS TO OMB.

By means of an electronic signature I understand I am agreeing to the terms listed above.

**Full Name:
**Initials:
**Date:

Funded in part through a cooperative agreement with the U.S. Small Business Administration. All opinions, conclusions or recommendations expressed are those of the author(s) and do not necessarily reflect the views of the SBA. All services extended to the public on a non-discriminatory basis. � 2012 University of Pennsylvania. All Rights Reserved.

Pennsylvania Department of Community & Economic Development