Alamogordo Small Business Development Center

Alamogordo Small Business Development Center

U.S. Small Business Administration
Request For Counseling Forms

Electronic Online Submission - Click Here
This option allows you to fill out the needed information for the SBA Form 641 and submit it online electronically to our office by e-mail.

Download a printable .pdf format - Click Here
This option allows you to download and print a hardcopy of the SBA Form 641. Follow the instructions to fill it out and mail it to our office. Note:This option requires Adobe Acrobat Reader. Most modern computers already have Adobe, however if you don't, you can download it for free.

OMB Approval No. 3245-0324
Expiration Date: 04/30/2003

SBA Form Instructions

The following step-by-step outline will aid in completing the Request for Counseling Form.

1. Type full name of the individual(s) requesting counseling.

2. Give telephone and FAX numbers including area code(s).

3. Type your email address.

4 - 8. Type your complete mailing address.

9 - 14. Mark all boxes as appropriate.

15. Describe the business function(s) for which you are seeking counseling. Some examples of such functions are Business Planning, Marketing, Sales, Financial Management, Insurance and legal Structure. If you are not currently in business, then describe the business you wish to start.

16. Mark all boxes as appropriate.

17. Describe the business you are currently running. This will help us to assign the most qualified counselor to your request.

18. Type the name of your company. Leave blank if you are not already in business.

19. Give length of time your company has been in business. Leave blank if you are not already in business.

20. Indicate preferred date(s) and time(s) for the first appointment with counselor.

1.Your Name (First, Middle, Last)

3. E-mail Address

2. Telephone Number(s)
Home
Business
Fax

4. Street Address

5. City

6. County

7. State

8. Zip

9. Race (Check One or More)
a. Native American
or Alaskan
b. Asian
c. Black or African American
d. Native Hawaiian or
other Pacific Islander
e. White

10. Ethnicity
a. Hispanic Origin
b. Not of Hispanic Origin

11. Business Owner Gender

a. Male
b. Female
c. Male/Female

12. Within the last two years
have you ever received:
a. Aid to Families
with Dependent Children (AFDC)
b. Temporary Assistance
to Needy Families (TANF)

13. Veteran Status
a. Veteran
b. Service-Connected Disabled Veteran
c. Disabled Veteran
d. Non-Veteran

14. How did you hear of us?
a. Word of Mouth b. Bank c. Newspaper d. Chamber of Commerce
e. Internet f. Radio g. Television h. Magazine i. Other j. SBA

15. Describe the nature of the counseling you are seeking:

16a. Currently in Business? (If No, Skip to Line 20) Yes No

16b. Is this a home-based business? Yes or No

17. Type of Business

18. Name of Company

19. How long in business?

20. Indicate preferred date and time for appointment:

Date:

Time:

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 designed 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 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 service. I waive all claims against SBA personnel, SCORE and its host organizations, and other SBA Resource Counselors arising from this assistance.

Please Note: The estimated burden for completing this form is 15 minutes per response. You will not be required to respond to this information collection if a valid OMB approval number is not displayed. If you have questions or comments concerning this estimate or other aspects of this information, please contact the U.S. Small Business Administration, Chief, Administrative Information Branch, Washington, DC 20416 and/or Office of Management and Budget, Clearance Officer, Paperwork Reduction Project (3245-0091), Washington DC 20503

Signature:(Full Name)

Date: