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Request For Counseling
* Indicates Mandatory Fields          
First Name:*  
Last Name:*  
Email Address:*    
Telephone Work:*
(ex:123-123-1234)   
Telephone Home:
(ex:123-123-1234)  
Telephone Cell:
(ex:123-123-1234)  
Fax:
Company Name:
Home Mailing Address:*  
Home City:*  
Home State:*  
Home Zip: *  
Company Mailing Address:
Company City:
Company State:
Company Zip Code:
Country :
Company Website :
Gender:*  
Ethnic Group:*




 
Veteran Status:
 
Reservist Status:



 
Disabled:*
 
Business Status:*



  
International Trade (Import/Export):*  
Primary Language Used:*



 
Date Business Established:*  (mm/dd/yyyy)  
Legal Entity of your business:*




  
Number of Employees Full Time:
Number of Part-Time Employees:
Annual Sales (last 12 months):
Business Ownership:*
 
Business Certification:*




 
Are you doing business online?*  
Are you a Home Based Business?*  
Please describe your type of business:*
     
Please describe your Product or Service:*
 
How did you find us?*








 
Please describe your consulting needs here, the more detailed the better so we can assign you the proper counselor.*
 
Electronic Signature:*

I request business management counseling from a Small Business Administration resource partner, the Small Business Development Center. I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA assistance services. I understand that any information received by an SBA resource partner counselor will be held in strict confidence by the counselor to the extent allowable by law.

I further understand that SBA resource partner counselors have agreed not to: (1) recommend goods or services from sources in which the individual counselor has an interest; and (2) accept fees or commissions developing from any SBA resource partner counselors. In consideration of the provision of management and/or technical assistance by a resource partner counselor, I agree to waive all claims arising out of this assistance, against SBA personnel, the resource partner from whom I sought assistance, its host organizations, and the counselor(s) arising from this assistance.
PLEASE TYPE YOUR NAME AND DATE BELOW. THIS IS YOUR ELECTRONIC SIGNATURE.

 
 
Please Type Today's Date*  (mm/dd/yyyy)  
Best way to contact you:*
 
Best time to schedule an appointment with Our Business Advisor*


 

South Bay areas 		 
 
  

  Peerspectives Orientation Date TBD

 
 
SBA Logo
The Lead Center for the Los Angeles Regional SBDC Network is operated by Long Beach Community College District. The Small Business Development Centers are funded by the US. Small Business Administration, the California Community Colleges Economic & Workforce Development Program, and center host Institutions. Funding is not an endorsement of any product, opinion, or services. All Federal and State funded programs are extended to the public on a nondiscriminatory basic. Special arrangements for individuals with disability will be made if requested in advance.
 HOSTED BY:
El Camino College,
Business Training Center,
13430 Hawthorne Blvd.,
Hawthorne, CA 90250

Tel (310) 973-3177  •  Fax (310) 973-3132
www.southbaysbdc.org 		Elcamino Logo
 
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