COUNSELING REQUEST FORM - (Form 641)

Filling out Form 641 is necessary in order for the American Samoa Small Business Development Center (SBDC) to provide free, one-on-one, confidential counseling to you.

However, filling out Form 641 does not guarantee that the American Samoa SBDC will provide such
counseling. A consultant for the SBDC will make a decision as to whether or not to engage in a consulting relationship based upon their available time and their ability to be of assistance to you.

In order for them to make this decision, you may be asked for additional information.

** = required information

1. YOUR NAME

**First:

Middle:

**Last:


2. TELEPHONE NUMBERS & ADDRESSES

Home:

Business:

Fax:

**Email :

Street:


City:

State

Zip Code:



3. RACE (Please check all that apply)

a.

b.

c.

d.

e.

4. ETHNICITY

a.

b.

5. BUSINESS OWNER GENDER

a.

b.

c.

6. WITHIN THE LAST TWO YEARS, HAVE YOU RECEIVED:

a. Aid to Families with Dependent Children

b. Temporary Assistance to Needy Families

7. VETERAN'S STATUS

a.

b.

c.

d.

8. HOW DID YOU HEAR OF US? (Please check all that apply)

a.

b.

c.

d.

e.

f.

g.

h.

i.

j.

9. DESCRIBE THE NATURE OF THE COUNSELING YOU ARE SEEKING:

10. CURRENTLY IN BUSINESS?

Is this a home based business?

11. TYPE OF BUSINESS:
12. NAME OF COMPANY:
13. HOW LONG IN BUSINESS?

NOTICE: BY SUBMITTING THIS FORM, YOU ARE AGREEING TO THE FOLLOWING:
I request business management counseling service from a Small Business Administration Resource Partner. I agree to cooperate should I be selected to participate in surveys designated to evaluate SBA assistance services. I authorize SBA to furnish relevant information to the assigned management counselor(s). I understand that any information disclosed will be held in strict confidence by him/her.

I further understand that any counselor has agreed 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 for the counselor(s) furnishing management or technical assistance, I waive all claims against SBA personnel, SCORE and its hostorganizations, and other SBA Resource Counselors arising from this assistance.