SCORE Erie Chapter 193- 641 III Form
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Counseling Information Sheet
Case Number:

1) Name: 2) Telephone:
3) E- Mail

4) Fax:

5) Street Address

6) City, State or Zip
7)Currently in Business  Yes No

8)Name of Business
9)Business Established (mo/yr)

10)Number of Employees  Full Part Time
11)  New Case       Follow-up       Close out       One Time
12) Legal Entity:  Sole Proprietorship  Partnership  Corporation  S-Corporation  LLC
13) Type of Counseling : Face to Face    Telephone    Online
14) Language (s) Used : English Spanish   Other
15) Primary area (s) of counseling:
a)Start-ups (How do I start a small business) d)Human Resources g)Intl. Trade
b)Business Plan e)Marketing/Sales h)Technology/Computers
c) Financial/Capital f) Franchises i) Buy/Sell Business
j) Other counseling provided:
16) How many persons attended the initial counseling session?  
17) Counselor's  Brief Notes:
18) Counselor's Name (s): 14) Date Counseled
19) Contact Hours 20) Prep Hours 21) Travel Hours   22) Mileage
23) Case Status   Closed Open
24) Has client been informed about other SBA resources? Yes No
25) Submitted by: (E-Mail address)

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