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Client Intake Form
I request business counseling service from the Northern California Small Business Development Center (SBDC) Network, an SBA Resource Partner.

I agree to cooperate should I be selected to participate in surveys designed to evaluate SBDC services. I understand that any information disclosed will be held in strict confidence. (The SBDC will not provide your personal information to commercial entities.) I authorize the SBDC to furnish relevant information to the assigned Business Advisor(s). I further understand that the advisor(s) agree 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, and that of its

Resource Partners, host organizations, and SBDC Advisors arising from this assistance.
By accepting these terms you agree, if selected, to participate in surveys designed to evaluate the services and impact of the Northern California SBDC Network. Any information disclosed in such surveys will be held in strict confidence.

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.

Name *
Your answer
Email *
Your answer
Phone *
Your answer
Address, city, state, zip *
Your answer
Client Signature *
Your answer
Race
Your answer
Ethnicity
Your answer
Gender
Your answer
Disabled?
Your answer
Veteran Status
Your answer
Military Reserve Status
Your answer
Referred by
Your answer
Are you currently in business? ( Answer "No" if you are potentially going to start a new business ) *
Name of Business
Your answer
Type of Business
Your answer
Business Ownership Gender
Your answer
Date Business Started
MM
/
DD
/
YYYY
Total FT/ PT Employees
Your answer
Gross revenue, sales for most recent year
Your answer
Organization type
Your answer
What is the nature of the counseling you are seeking?
Describe specific assistance requested
Your answer
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