SBDC at Blinn College

Consulting Intake Questionnaire

SECTION 1: Please complete this section

PERSONAL & CONTACT INFORMATION

Your full name:

E-Mail Address:

Daytime Phone:

Alternate Phone:

Fax:

Mailing Address:

City:

State:

Zip Code:

County:

Present Occupation:

When is the best time to contact you?

Check if you do NOT want to receive notices of future workshops:

DEMOGRAPHIC INFORMATION

The SBDC at Blinn College seeks to provide business counseling and training without regard to race, color, sex, age, national origin, religion, disability, or any other constitutionally or statutorily impermissible reasons. Funded in part through a cooperative agreement with the U.S. Small Business Administration. Funded in part by Blinn College. Arrangements for the physically handicapped are available upon individual request. Call Brazos Transit at 1-800-272-0039.

Gender:

Race:

Are you of hispanic origin?

Military status:

Are you disabled?

Your age:

Level of education completed:

Your household's annual income:

Are you a U.S. citizen?

Alien registration number:

BUSINESS INFORMATION

Please answer the following questions as they apply to your existing or proposed business:

Physical Location (if different than above)

Type of business:

Description of business:

Legal form of organization:

How many employees will you have, including yourself?

Full-time

Part-time

Do you have:

a fictitious name certificate (DBA)?

a written business plan?

a sales tax permit?

Are you doing—or do you plan to do:

international business?

business on the internet?

government contracting?

If you are already in business, skip Section 2 and go to Section 3

SECTION 2: Complete only if you are NOT yet in business.

START-UP INFORMATION

The business will be:

Your years of experience in this field:

Estimated start-up cost:

Will you need financing?

Amount you can invest in the business:

If you are NOT in business yet, skip Section 3 and go to the submit button

SECTION 3: Complete only if you ARE already in business.

EXISTING BUSINESS INFORMATION

Business Name

Mailing Address

City

County

State

Zip Code

Business Phone

Fax

Website URL:

How did you acquire the business?

Date of establishment or purchase:

What has your capital investment been?

Click once to send the form. If an e-mail appears, please send it.

We will call you within a few days to schedule an appointment for you to meet with a consultant. If you have any questions, please call (979) 830-4137

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