REQUEST FOR COUNSELING Should we recommend that you need to see a SCORE COUNSELOR in person, can you come to a SCORE office? Yes No   Validate Key Title *First Name *Last Name title Mr. Mrs. Ms. Dr. *Primary Phone Secondary Phone Fax *Street Address *City *State *Zip *E-mail Address

Preferred Time to Contact? No Preference Monday Tuesday Wednesday Thursday Friday No Preference Morning Noon Afternoon How would you like to be contacted? Email Phone   BUSINESS INFORMATION Name of Company: Type of Business: Legal Entity of your business Please Choose Below: Sole Proprietorship Partnership Corporation S-Corporation LLC Other

NATURE OF THE COUNSELING REQUEST Choose a primary category : Please Choose Below: Start-up (how do I start a small business?) Business Plan Financing/Capital (such as applying for a loan, building equity capital) Managing a Business Human Resources/ Managing Employees Customer Relations Accounting/Budget Cash Flow Mgt. Tax Planning Marketing/Sales (promotion, mkt. resch.,pricing, etc.) Govt. Contracting (including certifications) Franchising Buy/Sell Business Technology/Computers eCommerce (using the Internet to do business) Legal Issues (such as should I incorporate?) International Trade *Describe in detail the business project and the specific assistance requested in the space provided.

*Agreement to statement below required to submit form:

  Do Not Agree Agree   I request business counseling from SCORE, an SBA Resource Partner. I understand that any information disclosed will be held in strict confidence. SCORE or SBA will not provide my personal information to commercial entities. I authorize SCORE and SBA to furnish information to assigned counselor (s). I further understand that the counselor (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 SCORE and SBA, its personnel and host organizations, arising from such assistance.