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Request for Counseling

We receive our funding from a variety of grants, including the Small Business Administration (SBA).
Our continual funding depends on our ability to collect and report the following information.
All information collected is reported anonymously.  * Required fields are marked.

Personal Information

First Name *

MI *

Last Name *

Phone 1 *

Phone 2 *

Email *

Fax

Mailing Address *

City *

State *

Zip *

County *

Birth Date *

Demographic Information

Do you consider yourself a person with a disability?   Yes   No
Are you currently a client of DVR?   Yes   No

Do you have health insurance?   Yes   No

Gender

Family Type

Veteran Status

Military Status

Highest Education

Employment Status

Housing Status

Ethnicity

Race

Income Information

Answer the following questions based on last year's tax return.

Adults Dependents

Child Dependents

Estimated Gross Income
$

Do you receive any public assistance?

Food Shares
SSDI
Badgercare

Housing Assistance
W2

Do you receive income from any of these sources?

Social Security
Pension
SSI
TANF
Unemployment Insurance

General Assistance
Employment Only
Employment and Other Source
Other

Business Information

Business Address *

City *

State *

Zip *

Are you a home-based business?   Yes   No
Do you own your business?   Yes   No
Are you 8(a) certified?   Yes   No

Do you conduct business online?   Yes   No
Are you currently exporting products?   Yes   No
Have you had sales with your business?   Yes   No

Business Name

Business Type

Female Ownership (%)

Full Time Employees

Part Time Employees

Business Organization

Approx. Business Start Date

Total Sales in Last Tax Year

Net Profit/Loss Before Taxes Last Year
  Profit  Loss

Counseling Information

Please briefly describe your business. *

Please briefly describe the counseling your are seeking. *

Past business ownership and/or management experience

Preferred date(s) and time(s) for appointment

Do you have any special needs?   Yes   No

What is the nature of counseling you are seeking? (Choose primary category)

Start-Up Assistance
Business Plan
Managing a Business
Cash Flow Management
Financing/Capital
(such as applying for a long,
building equity capital)

HR/Managing Employees
Customer Relations
Business Accounting/Budget
Tax Planning
Buy/Sell Business
International Trade

Franchising
Technology/Computers
Marketing/Sales
(promotion, market
research, pricing, etc.)
Government Contracting
(including certifications)

eCommerce
(using the Internet
to do product sales)
Legal Issues
(such as, Should I Incorporate?)
Other

Additional Information

How did you hear about our program? (Check all that apply)

SBA
USEAC
SBDC
WBC

SBA Website
Internet
Bank
Lender

TV/Radio
Business Owner
Newspaper
Magazine

Chamber of Commerce
Word of Mouth
Educational Institution
Local Econ-Dev Office

Other Client
Other Source

Client Release

I request business counseling service from the Western Dairyland Business Center (WDBC), a resource partner of the Small Business Administration (SBA). I agree to cooperate should I be selected to participate in surveys designed to evaluate WDBC or SBA services. I permit WDBC and SBA the use of my name and address for WDBC or SBA surveys and information mailings regarding WDBC or SBA products and services. I understand that any information disclosed will be held in strict confidence. (WDBC and SBA will not provide your personal information to commercial entities.) I authorize WDBC and 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 WDBC and 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 18 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.
I have answered these questions completely and accurately to the best of my knowledge. *

Please print your full name *

Title

Date

Confirmation Code *