Register For Counseling

Surry Community College, Center for Public Safety

A secondary location of Surry Community College Small Business Center

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For all of the following questions, please answer regarding the existing or planned business that you would like counseling for.

First Name
Last Name
Zip Code	Enter your 5 digit Zip Code. If you don't have one or don't know your zip code, enter 00000

Business Name	Leave blank if you do not have a name chosen or the business name is the same as your name.
Position	Your position or title related to this business
Address	Your physical street address (number and street) of the business. If a home based business, or the business has not started yet, use your home address.
Address Line 2	Optional. Use if you need additional address postal information like apt, floor, suite, etc., or a PO box.
City
State

Please enter contact information regarding this business so that we may contact you if necessary

Primary Phone	The best phone number (with area code) to reach you during our standard business hours. Include extension if necessary.
Primary Phone Type	Type of the primary phone above
Secondary Phone	A secondary phone number to contact you, if we cannot reach you at the primary number.
Secondary Phone Type	Type of the secondary phone above

Web Site	Web site URL for the business
Business Description	Brief three to five word description of the business

Please answer the following demographic questions about yourself.

Race	Asian Black or African American North African Middle Eastern Native American/Alaska Native Native Hawaiian/Pacific Islander White Prefer not to say Other Check any that apply
Hispanic Ethnicity
Gender
LGBTQ
Disability	Do you consider yourself a person with a disability
Military Status
Branch of Service

Business Status

Business has started

Check if you have started conducting business. Leave unchecked if you are in the planning stages and have yet to start this business.

Since this business has started, please enter the following information.

Year Started	Year this business started
Month Started	Month this business started
Business Type	Primary category of business
Female Ownership %	% Enter the percent female ownership for this business.
Business Online	Yes If business is conducted online
Home Based Business	Yes If business is home based
8(a) Certified	Yes If you are currently 8(a) certified.

Business Organization

Legal entity of the business

Employees FT

Current Number of Full Time Employees

Employees PT

Current Number of Part Time Employees

Annual Sales $

Annual Sales $ for the most recent full business year

Annual P/L $

Annual Profit/Loss $ for the most recent full business year

Are you currently exporting

Yes

Export Employees	Current Number of Total Export Related Employees
Export Sales $	Export Related Sales for most recent full business year
Export Countries	Countries you are currently exporting to. Start typing the name of the country and a list will appear to choose from. You may select more than one.

How did you hear about us?
Assistance Requested	Business Accounting/Budget Business Plan Buy/Sell a Business Cash Flow Management Customer Relations Financing/Capital Franchising Government Contracting Human Resources/Employees International Trade Legal Issues Managing Business Marketing/Sales Social Media Start-up Assistance Tax Planning Technology/Computers Check all the kinds of assistance that you seek
Briefly describe the specific assistance you are requesting

Please read the following, enter your Full Name, and click Continue below to indicate your acceptance.

I request business counseling services from the Small Business Center Network (SBCN) through one of its directors or resource partners, and I agree to cooperate should I be selected to participate in surveys designed to evaluate these services. I permit the SBCN and its agents the use of my name and address for SBCN surveys and information mailings regarding SBCN products and services.

I authorize the SBCN to furnish relevant information to the assigned counselor(s).

I understand that any information disclosed will be held in strict confidence and that the SBCN will not provide my personal information to commercial entities. I further understand that the SBCN counselor(s) agrees not to: 1) recommend goods or services from sources in which he/she has an interest, or 2) accept fees or commissions developing from this counseling relationship. In consideration of the counselor(s) furnishing business startup, management or technical assistance, I waive all claims against SBCN personnel, its resource partners and host organizations.

By entering my full name here, I indicate my acceptance of the above terms.

Full Name:

Date: 4/25/2024 8:06:35 PM

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