U.S Small Business Administration
Electronic Request for Counseling - Internet

In order to qualify for counseling assistance, please provide the information below. Required Fields are Boldface. Press the Submit Button at the bottom of the page to process.
Section I:  General Contact Information
First Name        Last Name
Phone Number
E-mail (name@work.com)
Business Name (If known) Fax Number
Position (e.g. Owner)
Home Phone
State  Zip Code

Section II:  Demographic Profile

Since our program is federally funded, we are required to track client demographic data. Please choose the descriptions which most closely apply to you.



Are you of Hispanic Origin?     Yes No  
Are you a person with a Disability? Yes No  If Yes, do you need special assistance? Yes
Veteran Status:
Military Status:

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? (e.g. 7/4/1976)
  Is this business Home-Based?      Yes No
  How many full time employees do you currently have? (include owners)
  How many part time employees do you currently have?
  • Business Type:
  Legal Structure:  

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 Other (describe below)
Financial Business Plan
Indicate your preferred date & best time for an appointment.
We cannot guarantee this time, but we will try to accomodate your needs.

Section V: Client Agreement - Electronic Signature

   "I request business management counseling from the Small Business Administration resource partner, the New Jersey 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, NJSBDC and its host organizations, 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:

SBA Form 641 Federal Regulation - OMB Approval No. 3245-0324
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