Is this a new business you are starting? Yes No

Are you currently in business? Yes No

If yes, what date did your business start? mm/dd/yy

# of full-time employees

# of part-time employees

What are your annual sales?

Have you received NBDC assistance before? Yes No

If yes, when did you receive assistance? mm/dd/yy

Business size? Choose One Disadvantaged small Disadvantaged SBA (8a) Small Woman-owned small Minority-owned small Large Other Small

What is your business type? (select all that apply)

Not Classified
Manufacturer
Service
Retail
Wholesale
Construction

Briefly describe your products/services:

What is your race: Choose one Native American or Alaskan Native Asian Black or African American Native Hawaiian or other Pacific Islander White

What is your ethnicity? Not of Hispanic Origin Hispanic Origin

Business Owner Gender: Male Female Male/Female Partnership

What is your military veteran status? Choose One Veteran Service Connected Disabled Veteran Disabled Veteran Non-veteran

Indicate the nature of service and/or counseling you are seeking:

How did you learn about these counseling services? Choose One Unknown Yellow Pages Television Radio Newspaper Bank Chamber of Commerce Word of Mouth SBA Internet Other

PLEASE READ THIS STATEMENT, THEN SIGN AND DATE THIS FORM
I request management assistance from the Small Business Administration and/or the University of Nebraska at Omaha Small Business Development Center.  I understand this assistance is free of charge.  I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA/SBDC assistance services.  I authorize the SBA/SBDC to furnish information to the assigned management consultant(s). I understand that any information disclosed is to be held in strict confidence by him/her.

I further understand that any consultant has agreed: (1) not to recommend goods or services from sources in which he/she has an interest, and (2) will not accept fees or commissions developing from this consulting relationship.In consideration of SBA/SBDC furnishing management or technical assistance, I waive all claims against SBA/SBDC personnel and its host organizations arising from this assistance.

Electronic Signature:(enter your name) *
Date: * mm/dd/yy

By means of an electronic signature I understand I am agreeing to the terms listed above.  Initials: (enter your initials) *