If you are an entrepreneur in need of services that will help you grow your company, please complete and submit this form.  You will be contacted about support services that are available to you.

Your Name

Email

Home Phone

Business Phone

Position/Title

Proposed Company Name

Description of Proposed Business

County

Home Mailing Address

City

State

Zip

Type of Business (present or proposed) Construction Manufacturing Retail Service Technology Wholesale Other

How did you learn of these counseling services? Brochure Chamber of Commerce Financial Institution/Bank Friend/Word of Mouth Newspaper Radio SBA SBTDC Telephone Book Television Advantage West Internet Other

Status of Business Concept Start-up Operating Expansion Closing

Current or expected number of Employees Full Time Part Time

Type of Ownership Corporation Partnership Sole Proprietor Other

Business Ownership Male Female

Handicapped/Disabled Yes No

Ethnic Background White non-hispanic Black non-hispanic American Indian/Alaskan Hispanic Asian/Pacific Islander Other/Unknown/Multiple

Check the problem areas for which you need assistance (Check all that apply) Accounting and Records Business Feasibility Business Liquidation/Sale Business Plan Development Computer Systems Credit and Collections Engineering/R&D Estimating & Bidding Financial Analysis/Cost Control Government Procurement Inventory Control International Trade Legal Needs Management & Supervision Market Research Personnel Patents & Trademarks Source of Capital Other

Business Plan Yes No

Seeking Space Laboratory Office Manufacturing Warehouse

Where are you planning to locate your business? Please specify city, county, etc.

Amount of space?

Will you be seeking capital? If so, how much?

Will you be seeking additional management expertise?

Have you started a business before?

Have you participated in a Business Education course before?

Do you hold any patents? Yes No If so, do you intend to license or assign? Yes No

Will you be seeking research grants? Yes No

Have you completed a cash flow analysis of your business? Yes No

Rate your sales goals from 1-10

How soon will you reach break even?

What is your exit strategy?

If you have to raise capital, how would you use that money?

Has anyone in your family started a business?

Are you currently employed as a source of income?

Do you have a prototype?

Do you have specific educational or work experience in relation to your product? Yes No If so, please describe

What is the problem that your product solves?

What is your target market?

Who is your competition?

What are your barriers to entry?