Counseling Request Form

Filling out this form is necessary in order for the San Luis Valley BSC to provide free, one-on-one, confidential counseling to you.

However, filling out Form 641 does not guarantee that the San Luis Valley BSC will provide such counseling. A consultant for the San Luis Valley BSC 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: **

2. >>Telephone Numbers and 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 Businss? Yes No
.........Is this a Home_based business? Yes No 
10. >Type_of_business:
11. Name of Company:
12. How Long In_business
13. Mentor Preference: **

 

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