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You are here: Home / HOME / PROGRAMS / Request for Consulting Form

Request for Consulting Form

Please complete the following form to request consulting from the University of Mary Washington Small Business Development Center.

Request for Consulting

Part I: Client Request for Counseling
Name*
First Last
Email*
Primary Phone*
Address (give business address if currently in business)*
Street Address City State ZIP Code
I request business consulting service from the Small Business Administration (SBA) or an SBA Resource Partner. I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA services. I permit SBA or its agent the use of my name and address for SBA surveys and information mailings regarding SBA products and services.*
- Yes
- No
I understand that any information disclosed will be held in strict confidence. (SBA will not provide your personal information to commercial entities.) I authorize SBA to furnsih relevant information to the assigned management consultant(s). I further understand that the consultant(s) agrees 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 of the consultant(s) furnishing management or technical assistance, I waive all claims against SBA personnel, and that of its Resource Partners and host organizations, arising from this assistance. Please note: The estimated burden for completing this form is 18 minutes. Comments on the burden should be sent to: U.S. Small Business Administration, 409 3rd Street, SW, Washington, DC 20416, and to : Desk Officer SBA, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C., 20503. Please enter your full name, indicating your acceptance of the above terms.*
Part II: Client Intake (to be completed by all Clients)
Race (mark one or more)*
- American Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or other Pacific Islander
- White
- Prefer not to answer
Ethnicity*
- Hispanic or Latino
- Not Hispanic or Latino
- Prefer not to answer
Gender*
- Male
- Female
Do you consider yourself a person with a disability?*
- Yes
- No
Military Status*
- None
- Veteran
- Service Disabled Veteran
- On Active Duty
- Member of National Guard
- Member of Reserve
- Spouse of the Military Member
What prompted you to contact us?*
- SBA District
- Lender
- Business Owner
- Television/Radio
- SBA Website
- Magazine
- Newspaper
- Internet
- Other Client
- Educational Institution
- Local Economic Development Office
- Word of Mouth
- Chamber of Commerce
Are you currently in business?*
- Yes
- No
Name of Company
Type of Business (choose primary category)
- Mining
- Utilities
- Information
- Construction
- Retail Trade
- Manufacturing
- Finance & Insurance
- Wholesale Trade
- Public Administration
- Educational Services
- Real Estate & Rental & Leasing
- Health Care & Social Assistance
- Accomodation & Food Service
- Arts, Entertainment & Recreation
- Transportation & Warehousing
- Professional, Scientific & Technical
- Management of Companies & Enterprises
- Agriculture, Forestry, Fishing & Hunting
- Administrative & Support
- Waste Management & Remediation Services
- Other Services (except Public Administration)
What percentage of your business is male ownership?
What percentage of your business is female ownership?
Month & Year Business Started?
Do you conduct business online?
- Yes
- No
Are you a home based Business?
- Yes
- No
Are you 8(a) certified?
- Yes
- No
Total Number of Full Time Employees
Total Number of Part Time Employees
For your most recent full business year, what were your Gross Revenues/Sales $?
For your most recent full business year, what were your +Profits/-Losses $?
What is the legal entity of your business?
- Sole Proprietorship
- S-Corporation
- Corporation
- Partnership
- LLC
What is the nature of the consulting you are seeking?*
- Start-Up Assistance (How do I start a small business?)
- Business Plan
- Financing/Capital (such as applying for a loan, building equity capital)
- Managing a Business
- Human Resources/Managing Employees
- Customer Relations
- Business Accounting/Budget
- Cash Flow Management
- Tax Planning
- Marketing/Sales (promotion, market research, pricing, etc.)
- Government Contracting (including certifications)
- Franchising
- Buy/Sell Business
- Technology/Computers
- eCommerce (using the internet to do business)
- Legal Issues (such as, Should I incorporate?)
- International Trade
Describe specific assistance requested in the space provided.*
In order for the SBDC to meet your consulting needs, please answer the following questions as completely as possible.
Briefly describe your existing or proposed business venture and where it is (or will be) located.*
Do you now or have you ever owned a business?*
Please describe your business ownership or business management experience.*
Who are (or will be) your customers?*
Who is (or will be) your main competition?*
How your business is (or will be) better than your competition?*
How your business is (or will be) financed?*
Client Rights and Responsiblities
Please read the following and place a checkmark in the box to signify that you have read and agree to the Clients Rights and Responsibilities.
*
- 1. You are entitled to be treated with courtesy and consideration by your consultant and other UMWSBDC personnel.
*
- 2. You are entitled to professional consulting services and be advised if the UMWSBDC is unable to provide services within the time frame required.
*
- 3. You have the right to privacy regarding information shared with the UMWSBDC. No information provided by you will be used to the commercial or other advantage of any staff member, consultant, or other resource of the UMWSBDC or to the advantage of any third party.
*
- 4. You are entitled to confidentiality of your client status with UMWSBDC. No public use of your name, address or business identity will be made without your expressed written prior approval. UMWSBDC is required to provide limited information with respect to your client status to the U.S. Small Business Administration.
*
- 5. You will receive email notifications from UMW SBDC but you will have the option to unsubscribe anytime you want to. ( By signing this form, you are agreeing to receive emails from UMW SBDC email platform).
*
- 6. You are entitled to be charged a reasonable fee for training programs, special services, and publications. However you have the right to feel secure that no fee will be charged by UMWSBDC for the normal consulting services provided to you.
*
- 7. You may not be refused services on the basis of race, creed, color, religion, sex, age, national origin or disability.
*
- 8. Your acceptance of management and technical assistance from UMWSBDC means that you agree to waive all claims against UMWSBDC and its staff or any other resources employed by or used in connection with these services.
*
- 9. You are expected to cooperate with the UMWSBDC in its efforts to assure the quality and effectiveness of the consulting services it provides.
*
- 10. You are required to complete a brief impact assessment at the end of each calendar year in order to continue services.
Please enter your full name and today's date on the line below to signify that you have read and agree to the Clients Rights and Responsiblities as listed above.

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