Section I:  General Contact Information 

 First Name:      Last Name:     Phone Number ()

 E-mail (name@work.com):    Business Name (If Known):

 Address:   City:   State:   Zip Code:

Section II: Demographic Profile

 Since the Connecticut Small Business Development Center is a federally funded program we are required to track client demographic data.  Please choose the description that applies to you.

 Race:   Select Race White African American Asian Native American Hawaiian or Pacific Islander Latin American       Gender: Male Female       Are you of Hispanic Origin?  Yes No

 Are you a person with a Disability?  If Yes, check here.

 Veteran Status: Select Veteran Status Not a Veteran Veteran Serviced Disabled Veteran     Military Status:  Select Military Status Not Military Reserve/National Guard On Active Duty

Section III:  Business Profile

 Are you Currently in Business?  Yes  No - I want to Start a Business

 If Yes:  What was your Business Start Date?    (i.e. 6/2/2006)   Is this Business based at Home?  Yes No

 How many Full Time employees do you currently have?  (include owners)

 How many Part Time employees do you currently have?     Business Type:  Select Business Type Agriculture Mining Utilities Construction Manufacturing Trade Warehousing Transportation Information Finance and Insurance Real Estate Scientific/Technical Services Management Company Administrative and Support Educational Services Health Care Social Assistance Arts, Entertainment, Recreation Accomadation Food Services Other Public Administration

 Legal Structure:  Select Structure Sole Proprietor Partnership Corporation S-Corporation Limited Liablility Corporation (LLC) Not Identified

Section IV:  Nature of Assistance

 Describe your business/idea in 3 to 5 words: 

 What kind of Assistance do you seek?  (Check at least one or all that apply below):

Start Ups                         Human Resources                   Buy/Sell a Business                    Capital Sources                     Technology                           Franchises                      

Marketing/Sales                      International Trade                    Financial                               Business Plan

 Other and/or referral code =

 Indicate your preferred date    and best time  Morning Afternoon Early Evening   for an appointment.

Section V: Client Agreement - Electronic Signature

        "I request business management counseling from the Small Business Administration resource partner, the Small Business Development Center.  I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA or SBDC assistance services.  I understand that any information received by an SBDC resource counselor will be held in strict confidence by the counselor to the extent allowable by law."

        "I further understand that any counselor has agreed: (1) not to recommend goods or services from sources in which he/she has an interest, nor (2) accept fees or commissions developing from this relationship.  In consideration of SBA's furnishing management or technical assistance, I agree to waive all claims against SBA personnel, SCORE, SBDC and its host organizations, SBI, and other SBA resource counselors arising from this assistance."

I, , accept this Agreement by typing "I Accept" as my electronic signature.

Type "I Accept"   Application Date: