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U.S. Small Business Administration OMB Approval No.:3245-0324 Expiration Date: 10/31/2020 Counseling Information Form Client Number: Location Code: Initials of Data Inputter:1. Name of the Office Providing the Service _______________________________1a
Ohio SBDC at Terra State Community College Type of Client: Face to Face Online Telephone2. City/State of Office Location_________________________ Fremont, OhioPART I: Client Request for Counseling3. Client Name (Name of the person completing the form/representative of the business) 4. Email (Last, First, MI)5. Telephone 6. Fax Primary Secondary7. Street Address/PO Box (give business address if currently in business) 8. City 9. State 10. Zip +411. 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 insurveys 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 andservices (Yes No ). I understand that any information disclosed will be held in strict confidence. (SBA will not provide your personal information to commercial entities.) Iauthorize 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 servicesfrom 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) furnishingmanagement or technical assistance, I waive all claims against SBA personnel, and that of its Resource Partners and host organizations, arising from this assistance
Use of Information: The information in this form is to be provided by individuals and business seeking technical assistance services from the Small Business Administration(SBA) or an SBA Resource Partner. The information is collected to help SBA's continuing improvement of business counseling programs, to ensure effective oversight andmanagement of entrepreneurial development programs and grants, and to meet Congressional and Executive Branch reporting requirements. The form should be submitted at the site of service to the counselor providing the service. Resource Partners will submit information to SBA according to the terms of their notice of award
12. Preferred date & time for appointmentDate: Time: 13. Client Signature Date:PART II: Client Intake (to be completed by all Clients)14. Race (mark one or more) 15. Ethnicity 16.Gender 17. Do you consider American Indian or Alaska Native Hispanic or Latino Male yourself a person with Asian Not Hispanic or Female a disability? Black or African American Latino Yes No Native Hawaiian or Other Pacific Islander White18. Veteran Status No military, Reserve, or Veteran Member of the Reserve Member of the National Guard National Guard service Service-Disabled Veteran Active Duty Spouse of Military Member19. Referred by? (Mark all that apply) SBA District SBDC Other Client Magazine/Newspaper Other (specify) Lender SCORE Educational Institution Word of Mouth USEAC Business Owner WBC Local Economic Development Official Television/Radio Boots to Business SBA Web site VBOC Chamber of Commerce Internet (please indicate website)20a. Are you currently in business? Yes No (if no, skip to 30) 20b. If yes, are you currently exporting? Yes NoIf yes to 20b, please go to Appendix A on page 3 to indicate the markets to which your company currently exports (mark all that apply)
21. Name of Business22. Type of Business (choose primary category) Professional, Scientific & Technical Services Mining Manufacturing Real Estate & Rental & Leasing Management of Companies & Enterprises Utilities Finance & Insurance Health Care & Social Assistance Agriculture, Forestry, Fishing & Hunting Information Wholesale Trade Accommodation & Food Services Administrative & Support Construction Public Administration Arts, Entertainment & Recreation Waste Management & Remediation Services Retail Trade Educational Services Transportation & Warehousing Other Services (except Public Administration)23. Business Ownership – What percentage of 24. Date Business 25. Do you conduct 26a. Are you a home based business Yes Noyour business is male or female owned? Started?(MM/YYYY) business online? 26b. Are you 8(a) certified? Yes No__________% Male__________% Female Yes No27a. Total No. of Employees 28a. For your most recent full business year, what 29. What is the legal entity of your business?(full & PT) were your: Gross Revenues/Sales $ Sole Proprietorship Corporation LLC27b. Of total employees, how many are +Profits/-Losses $ S-Corporation Partnershipengaged in the exporting aspect of your 28b. Amount of your Gross Revenues/Sales Other (specify) ________________________________business: (Full & PT) related to exporting $30. What is the nature of counseling you are seeking? (Choose primary category) Start-up Assistance (How do I start a Human Resources/ Marketing/Sales (promotion, market Technology/Computers small business?) Managing Employees research, pricing, etc.) eCommerce (using the Business Plan Customer Relations Government Contracting (including Internet to do business) Financing/Capital (such as applying Business Accounting/ certifications) Legal Issues (such as, for a loan, building equity capital) Budget Franchising Should I incorporate?) Managing a Business Cash Flow Management Buy/Sell Business International Trade Tax PlanningDescribe specific assistance requested in the space provided. ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________SBA Form 641 (10/24/2017) U.S. Small Business Administration OMB Approval No.: 3245-0324 Counseling Information Form Expiration Date: 10/31/2020 Client Number: Location Code: Initials of Data Inputter: Funding Source:Part III: Counselor Record31. Client Name (please use the same name from original 641 Part 1) 32. Email (Last, First, MI)33. Telephone 34. Fax Primary Secondary35. Street Address /P.O. Box 36. City 37. State 38. Zip +439a. Is the client currently in business? Yes No (if no, skip to 44) 40. Date Business39b. Is the client currently exporting? Yes No Started?If yes, please turn to Appendix A on page 3 to indicate the markets to which your client currently exports (mark all thatapply)
41a. Total No. of Employees: (Full & PT) 42a. As of the most recent full business year, what were the client's annual:41b. Of total employees, how many are engaged in Gross Revenues/Sales $_____________________ +Profits/-Losses $the exporting aspect of client's business?: 42b. As of the most recent full business year, how much of your client's Gross (Full & PT) Revenues/Sales were related to exporting? $43. SBA or Resource Partner Service Contributed to the Following: (Mark all that apply)SBA Loan Amount $ Certifications SBA Financial Assistance 8(a) Export ExpressNon-SBA Loan Amount $ Hubzones Export Working Capital LoanAmount of Equity Capital Received $ SDB Community Advantage Other (specify state, local, etc) Micro loanNo. of Government Contracts/Subcontracts SBIRAnnual Value of Government Contracts/Subcontracts Received Other (SBIR, SBIC, 7(a) 504, etc)$44. What was the nature of the counseling you provided the client? (choose primary category) Start-up Assistance (How do I start a Human Resources/Managing Marketing/Sales (promotion, Technology/Computers small business?) Employees market research, pricing, etc.) eCommerce (using the Internet Business Plan Customer Relations Government Contracting to do business) Financing/Capital (such as, applying Business Accounting/Budget (including certifications) Legal Issues (such as, Should I for a loan, building equity capital) Cash Flow Management Franchising incorporate?) Managing a Business Tax Planning Buy/Sell Business International TradePlease specify other counseling provided
45. Referred Client to (mark all that apply): WBC SBA District Office Export/Import Bank Dept of Commerce VBOC SCORE USEAC OPIC Dept of State PTAC SBDC State Trade Agency Dept of Agriculture U.S. Trade & Development Agency Other46. Type of Session 47. Language(s) Used 48. History 49. Date Counseled Face to Face Online Update English Other (specify) New Case Follow-up (MM/YYYY) Telephone Prep Spanish One Time50. Counselor(s) Name (If multiple counselors, list lead counselor first and separate 51. Contact Hours 51b. Prep Hourseach additional counselor name by a semi-colon): Total contact hours Total amount of that a client received preparation spent by all counselors for a client51c.Travel Hours Total amount of time it takes to travel to a client's location for counseling52 Did more than one Counselor participate in this counseling session? Yes__ No__. If yes, how many counselors ________?53. Counselor’s Notes:SBA Form 641 (10/24/2017) 2 U.S. Small Business Administration OMB Approval No.:3245-0324 Expiration Date: 10/31/2020 Counseling Information Form Client Number: Location Code: Initials of Data Inputter: Appendix A to Questions 20b. & 39b
If your company is currently exporting, please indicate the countries to which your company exports: (Mark all that apply) Asia Africa Caribbean Central America North America Afghanistan Algeria Anguilla Belize Bermuda Bahrain Angola Antigua & Barbuda Costa Rica Mexico Bangladesh Benin Aruba El Salvador Canada Belarus Botswana Bahamas Guatemala Bhutan Burkina Faso Barbados Honduras Burundi Virgin Islands (British) Brunei Cameroon Nicaragua South America Burma Cayman Islands Panama Cambodia Cape Verde Cuba China Central African Republic Dominica Argentina East Timor Chad Dominican Republic Europe Bolivia Georgia Comoros Grenada Austria Brazil Hong Kong Congo Haiti Azerbaijan Chile India Democratic Republic of Congo Jamaica Albania Colombia Indonesia Cote d'Ivoire Montserrat Armenia Ecuador Iran Djibouti Netherlands Antilles Belgium Guyana Iraq Egypt St. Kitts and Nevis Bosnia-Herzegovina Paraguay Israel Equatorial Guinea St. Lucia Bulgaria Peru Japan Eritrea St. Vincent and Grenadines Croatia Suriname Jordan Ethiopia Trinidad and Tobago Cyprus Uruguay Kazakhstan Gabon Czech Republic Venezuela Korea, North Gambia Denmark Oceania Korea, South Ghana Estonia Australia Kuwait Guinea Finland New Zealand Kyrgyzstan Guinea-Bissau France Cook Islands Laos Kenya Germany Fiji Lebanon Lesotho Greece Kiribati Macau Liberia Hungary Marshall Islands Malaysia Libya Iceland Nauru Maldives Madagascar Ireland Palau Micronesia Malawi Italy Papua New Guinea Mongolia Mali Latvia Samoa Nepal Mauritania Liechtenstein Solomon Islands Oman Mauritius Lithuania Tonga Pakistan Morocco Luxembourg Tuvalu Philippines Mozambique Macedonia Vanuatu Qatar Namibia Malta Russia Niger Moldova Nigeria Monaco Saudi Arabia Montenegro Other Singapore Rwanda Sri Lanka Sao Tome and Principe Netherlands Norway Subcontractor for Exporter Syria Senegal Tajikistan Seychelles Poland _____________________ Taiwan Sierra Leone Portugal Thailand Somalia Romania Turkey South Africa Serbia Turkmenistan Sudan Slovak Republic United Arab Emirates Swaziland Slovenia Uzbekistan Tanzania Spain Vietnam Togo Sweden Yemen Tunisia Switzerland Uganda Turkey Zambia Ukraine Zimbabwe United Kingdom Vatican CityPlease 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 OMBapproval 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, Officeof Management and Budget, New Executive Office Building, Room 10202, Washington, D.C., 20503. OMB Approval (3245-0324). PLEASE DO NOT SEND FORMS TO OMB
SBA Form 641 (10/24/2017) 3
WebU.S. Small Business Administration OMB Approval No.:3245-0324 Expiration Date: Counseling Information Form Control Number: SAM ID: 1. Name of the Office Providing the Service 1a. Type of Client: Face to Face Online Telephone 2. City/State of Office Location_____ PART I: Client Request for Counseling
SBA Form 641 is used to collect information from the Agency's resource partners, including: Small Business Development Centers, SCORE, and Women's Business Centers that provide training and counseling to existing or potential small business owners through SBA funded grants, or cooperative agreements.
Small Business Administration (SBA) Contact: Contact the Small Business Administration. Local Offices: Find an Office Near You. Main Address: 409 3rd St., SW Washington, DC 20416. Email: [email protected] Toll Free: 1-800-827-5722. TTY: 1-704-344-6640. Forms: Small Business Administration Forms. Government branch: Independent Agency
The Small Business Administration helps Americans start, build and grow businesses. Through an extensive network of field offices and partnerships, the Small Business Administration assists and protects the interests of small business concerns. SBA.