North Carolina Community College System SBCN
Electronic Request for Counseling - Internet

In order to qualify for counseling assistance, please provide the information below. Required Fields are Boldface. Press the Submit Button at the bottom of the page to process.
Section I:  General Contact Information
First Name        Last Name
Phone Number
()
E-mail (name@work.com)
Business Name (If known) Fax Number
()
Position (e.g. Owner)
Address
Home Phone
()
 
City
   
State  Zip Code
 

Section II:  Demographic Profile

Since our program is federally funded, we are required to track client demographic data. Please choose the descriptions which most closely apply to you.

Race:

Gender:

Are you of Hispanic Origin?     Yes No  
Are you a person with a Disability? Yes No  If Yes, do you need special assistance? Yes
Veteran Status:
Military Status:

Section III:  Business Profile

Are you Currently in Business? Yes No - I want to Start a Business
If Yes:
What was your Business Start Date? (e.g. 7/4/1976)
  Is this business Home-Based?      Yes No
  How many full time employees do you currently have? (include owners)
  How many part time employees do you currently have?
  • Business Type:
  Legal Structure:  

Section IV: Nature of Assistance

Describe your business/idea in 3 to 5 words:
What kind of assistance do you seek?  (Check at least one or all that apply below:)
Start-ups Human Resources Buy/Sell a Business
Capital Sources Technology Franchises
Marketing/Sales International Trade Other (describe below)
Financial Business Plan
Indicate your preferred date & best time for an appointment.
We cannot guarantee this time, but we will try to accommodate your needs.

Section V: Client Agreement - Electronic Signature

I request management assistance from The Community College Small Business Center. I agree to cooperate should I be selected to participate in surveys designed to evaluate the assistance services.

I will furnish relevant information to the Director of the Small Business Center although I expect that information to be held in strict confidence by him/her.

I further understand that the SBC personnel have agreed not to recommend goods or services from sources in which he/she has an interest and accept fees or commissions developing from this counseling relationship. In consideration of the community college Small Business Center furnishing management or technical assistance, I waive all claims arising from this assistance against the center, The Community College, its employees, and the State of North Carolina.
I, , accept this Agreement by typing "I Accept" as my electronic signature.
 

Type "I Accept"  Application Date:

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