U.S. SBA Form 641 Request for Counseling
Please read the instructions before filling out the form.

Please complete each section of the form and press the BUTTON marked "Submit Completed Form to Score". You can print out a hardcopy of your completed form before you submit it, and take it with you to the Outer Banks' SCORE offices located within the Chamber of Commerce building in Kill Devil Hills, NC. A separate copy of the completed form will be emailed to a SCORE official who will process your request. If you have the Adobe Acrobat Reader, you can download and print out the instructions as well as the 641 form as a pdf file.

If you have come to this page and are not located on North Carolina's Outer Banks, we suggest you locate the SCORE office nearest you.

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1. Your Name (First, Middle, Last)
, ,

2.a. Home Telephone
2.b. Business Telephone
2.c. Fax Number

3. E-Mail Address

4. Street Address      5. City
6. County      7. State      8. Zip

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9. Race (Use Ctrl or Command key for multiple selections)
Native American or Alaskan Native Asian Black or African American Native Hawaiian or other Pacific Islander White

10. Ethinicity
Hispanic Origin Not of Hispanic Origin

11. Business Owner Gender
Male Female Male/Female

12. Within the last two years, have you ever received:
    a. Aid to Families with Dependent Children (AFDC) yes no
    b. Temporary Assistance to Needy Families (TANF) yes no

13. Veteran Status
Veteran Disabled Veteran Service Connected Disabled Veteran Non-Veteran

14. How did you hear of us?
Word of Mouth Bank Newspapers Chamber of Commerce Internet Radio Television Magazine SBA Other

15. Describe the nature of the counseling you are seeking.

16.a. Currently in business? yes no      16.b. Is this a Home-based Business? yes no

17. Type of Business      18. Name of Company

19. How long in business?

20. Indicate preferred date and time for appointment
Date Time

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I request business management counseling from the Small Business Administration Resource Partner. I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA assistance services. I authorize SBA to furnish relevant information to the assigned management counselor(s). I understand that any information disclosed will be held in strict confidence by him/her.

I further understand that any counselor has agreed not to: (1) recommend goods or services from sources in which he/she has an interest and (2) accept fees or commissions developing from this counseling relationship. In consideration of counselor(s) furnishing management or technical assistance, I waive all claims against SBA personnel, SCORE and its host organizations, and other SBA Resource Counselors arising from this assistance.

Please note: The estimated burden for completing this form is 15 minutes per response. You will not be required to respond to this information collection if a valid OMB approval number is not displayed. If you have questions or comments concerning this estimate or other aspects of this information, please contact the U.S. Small Business Administration, Chief, Administrative Information Branch, Washington, DC 20416 and/or Office of Management and Budget, Clearance Officer, Paperwork Reduction Project (3245-0091), Washington, DC 20503.

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Upon completion press the BUTTON marked
"Submit Completed Form to Score".

Please return to the top of the page and then review your form
to make sure it is both complete and correct.

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Instructions for U.S. SBA Form 641 Request for Counseling

Please make sure the form is both complete and correct. You can print out a hardcopy of your completed form before you submit it, and take it with you to the Outer Banks SCORE offices located within the Chamber of Commerce building in Kill Devil Hills, NC. You can always check to see where the nearest SCORE office is to your location.

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1.	Individuals full name
2.	Telephone numbers including area code
3.	If applicable include email address
4-8.	Full address (complete as indicated)
9-13.	Complete as indicated
14.	Complete as indicated
15.	Explain the type of counseling you are seeking. We will attempt to match a counselor to you that has expertise in the area(s) in need of counseling.
16.	Complete as indicated. If not in business, skip to question 20.
17.	What is the nature of your business (i.e., retail, restaurant, manufacturing, service, etc.)
18.	Full name of company. Leave blank if not yet in business.
19.	Length of time in business. Leave blank if not yet in business.
20.	Enter the dates and times you are available for counseling.

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