Register For Counseling

MSBDC Central Regional Office

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Please answer the following questions regarding your existing or planned business.

First Name
Last Name
Zip Code	Enter your 5 digit Zip Code. If you don't have one or don't know your zip code, enter 00000

Business Name	Leave blank if you do not have a name chosen or the business name is the same as your name.
Position	Your position or title related to this business
Address	Your physical street address (number and street) of the business. If a home based business, or the business has not started yet, use your home address.
Address Line 2	Optional. Use for additional address postal information like apt, floor, suite, etc., or a PO Box.
City
State

Please enter contact information regarding this business so that we may contact you if necessary

Primary Phone	The best phone number (with area code) to reach you during our standard business hours. Include extension if necessary.
Primary Phone Type	Type of the primary phone above
Secondary Phone	A secondary phone number to contact you, if we cannot reach you at the primary number.
Secondary Phone Type	Type of the secondary phone above

Web Site	Web site URL for the business
Business Description	Brief three to five word description of the business

Please answer the following demographic questions about yourself.

Race	White Black Asian Native American/Alaskan Hawaiian/Pacific Check any that apply
Hispanic Ethnicity
Gender
Disability	Do you consider yourself a person with a disability
Military Status

Important Note: The US Small Business Administration defines in-business as: you have registered with the local, state, and/or Federal Government (e.g., DBA registration, get a business license, agency issued tax identifications, etc.) as applicable and required, and has at least one of the following:

documented a transaction from the sale of a product or professional or personal service for the purpose of gain or profit; or

contracted for or compensated an employee(s) or independent contractor(s) to perform essential business functions; or

acquired debt or equity capital to pursue business operations (e.g., to purchase inventory, equipment, building, business, etc.); or

incurred business expenses in the operation of a business beyond registration expenses; or

for IP-based entities only, are actively pursuing non-dilutive capital.

Business Status

Currently In Business

Check only if you are Currently In Business. Leave unchecked if you are in the planning stages and have yet to start this business.

Please enter the following information for your business.

Year Started	Year this business started
Month Started	Month this business started
Business Type	Primary category of business
Female Ownership %	% Enter the percent female ownership for this business.
Business Online	Yes If business is conducted online
Home Based Business	Yes If business is home based
8(a) Certified	Yes If you are currently 8(a) certified.

Business Organization

Legal entity of the business

Employees FT (including yourself)

Current Number of Full Time Employees

Employees PT (including yourself)

Current Number of Part Time Employees

Annual Sales $

Annual Sales $ for the most recent full business year

Annual P/L $

Annual Profit/Loss $ for the most recent full business year

Are you currently exporting

Yes

Export Employees	Current Number of Total Export Related Employees
Export Sales $	Export Related Sales for most recent full business year
Export Countries	Countries you are currently exporting to. Start typing the name of the country and a list will appear to choose from. You may select more than one.

Preferred Meeting Method	While we will try to accommodate your request, we cannot guarantee this type of meeting is available.
How did you hear about us?
Assistance Requested	Business Accounting/Budget Business Plan Buy/Sell a Business Cash Flow Management Customer Relations eCommerce Financing/Capital Franchising Government Contracting Human Resources/Employees International Trade Legal Issues Managing Business Marketing/Sales Start-up Assistance Tax Planning Technology/Computers Check all the kinds of assistance that you seek
Do you request a specific advisor? If YES, insert advisor name.
Briefly describe the specific assistance you are requesting

Please read the following, enter your Full Name, and click Continue below to indicate your acceptance.

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 in surveys 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 and services

I understand that any information disclosed will be held in strict confidence. (SBA will not provide your personal information to commercial entities.) I authorize 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 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 and host organizations, arising from this assistance.

I understand that any engagement I may pursue with any advisor outside of the programming and assistance provided in connection with the MSBDC is outside the scope of MSBDC’s counseling program.

I self-certify that neither I nor my company are currently in suspension or debarment by a Federal Agency.

Please enter your full name, indicating your acceptance of the above terms.

Full Name:

Date: 3/22/2023 9:36:31 PM

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