COUNSELING REQUEST FORM - (Form 641)
Filling out Form 641 is necessary in order for the Northland Pioneer College SBDC 
to provide free, one-on-one, confidential counseling to you.

However, filling out Form 641 does not guarantee that the Northland Pioneer College SBDC
will provide such counseling. A consultant for the Northland Pioneer College 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:
SSN:
2. TELEPHONE NUMBERS & ADDRESSES
Home:
Business:
Fax:
**Email :
STREET:
CITY:
STATE:
ZIP CODE:
3. RACE (Mark one or more)
a.Native American or Alaskan Native
b.Asian
c.Black or African American
d.Native Hawaiian or other Pacific Islander
e.White
4. ETHNICITY
a.Hispanic Origin
b. Not of Hispanic Origin
5. BUSINESS OWNER GENDER
a.Male
b.Female
c.Male/Female (Co-owners)
6. WITHIN THE LAST TWO YEARS, HAVE YOU RECEIVED:
a. Aid to Families with Dependent Children Yes No
b. Temporary Assistance to Needy Families Yes No
7. VETERAN'S STATUS
a.Veteran
b.Disabled Veteran
c.Vietnam Era Veteran
d.Non-veteran
8. DESCRIBE THE NATURE OF THE COUNSELING YOU ARE SEEKING
............AND/OR SELECT TOPICS FROM THE LIST BELOW: (check all that apply)
a.Start-Up/Acquisition
b.Source of Capital
c.Marketing Sales
d.Government Procurement
e.Accounting & Records
f.Financial Analysis/Cost Control
g.Inventory Control
h.Engineering R&D
i.Personnel
j.Computer Systems
k.International Trade
l.Technology
9. CURRENTLY IN BUSINESS? Yes No
Is this a home based business? Yes No 
10. TYPE OF BUSINESS:
11. NAME OF COMPANY:
12. 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 host organizations, and other
SBA Resource Counselors arising from this assistance.