UNI RBC: Request for Counseling Form

Request For Counseling Form

You should only fill out this form when directed to by staff at the UNI Regional Business Center. It is intended for people receiving email or phone counseling, or for those who would like to complete the paperwork prior to an in-person counseling session. Clients are responsible for scheduling all appointments. The RBC will not follow-up on form submissions unless you contact us first. For more information about our counseling services, visit our Counseling page.

In order to deliver counseling to our clients, we must collect certain personal, demographic, and business information. You can submit this information in one of three ways:

Fill out the Request for Counseling form electronically (see below). Once you submit this form, it will be delivered by email to counselors at the UNI Regional Business Center. Email submission is not secure; we cannot guarantee that this information will remain confidential while in transit.

Download the Request for Counseling form (PDF format, 105kb), print and fill it out manually, and either mail or fax it back to us.

Come by our office and fill out a form prior to meeting with a counselor.

The estimated time it will take to complete this form is approximately 5 minutes. All items marked with an asterisk (*) in the form below are required fields.

Request For Counseling Form

Have you previously received counseling from us? Yes No

How did you hear about us?
Internet
Newspaper
Chamber
Banker
Word of Mouth
Other, please specify:

Personal Information

*Last Name:
*First Name:
Middle Initial:
*E-mail address:
*Last 4 Digits of Social Security #

Second contact person (if applicable):

*Mailing Address:
*City:
*State: *Zip:

*County:

If you live in Iowa, and your county is not listed here, contact your regional Small Business Development Center for assistance.

*Day Phone (include area code):
Evening Phone (include area code):
Fax (include area code):

Demographic Information

*Gender:
Male
Female

*Race / Ethnicity:
African American
American Indian / Alaskan Native
Asian / Pacific Islander
Caucasian
Hispanic
Other, please specify:

*Veteran Status:
Veteran
Vietnam Veteran
Disabled Veteran
Not a Veteran

Business Information

*Choose one:
Pre-venture (Not yet in operation or in the launch phase)
Existing Business (Open for business 6 months or more)
Purchasing an existing business

Are you / will you be:
the owner
the manager
the staff
other, please specify:

What type of business do you represent?
Retail
Wholesale
Manufacturing
Trades
Service
Other, please specify:

*SBA Relationship:
Borrower
Applicant
None

Number of Employees (including owner): Full: Part:
Annual gross sales: $ in year (i.e.2002):
Year Founded:
*NAICS Code: (Find your NAICS Code)

*Type of ownership:
Sole Proprietor
Partnership
S Corporation
Limited Liability Company
C Corporation
Undecided

In the past two years, have you received:
Aid to Families with Dependent Children Yes No
Temporary Assistance to Needy Families Yes No

Check if any apply:
Family Business
Home-Based Business
Iowa Women's Enterprise Center

*Brief Description of the Business or Business Idea:

*How can the SBDC Help You?

Please read the following statement, initial and then click submit.

Hold Harmless Confirmation
I request business training from the UNI Regional Business Center (RBC). I agree to cooperate should I be selected to participate in surveys designed to evaluate RBC training services.

I authorize RBC to furnish relevant information to the assigned trainer, although I expect that information to be held in strict confidence by him/her. I have read and understand the Disclaimer provided by the US Small Business Administration.

I further understand that each trainer has agreed not to recommend goods or services from sources in which he/she has an interest. In consideration of RBC's furnishing management or technical assistance,

I waive all claims against RBC personnel, SBDC, SCORE, SBA and its host organizations, and other RBC Resource Counselors arising from this assistance.

In compliance with Iowa Code Section 22.11, the "Iowa Fair Information Practices Act," the University of Northern Iowa Regional Business Center (UNI RBC) requests this information for the purpose of rendering or evaluating UNI RBC services.

No persons outside the UNI RBC and US Small Business Administration are routinely provided this information. Release of this information is governed by the US Small Business Administration rules and applicable state and federal statutes. If you fail to provide the required information, the UNI RBC may elect not to provide business counseling services.

By initialing and submitting this form, I agree that I have read and agree to the terms stated above. Initials: