FIELDS MARKED WITH (*) ARE REQUIRED
NAME
First Name(*)
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Last Name(*)
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CONTACT INFORMATION
Email(*)
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What is your preferred contact phone number? (use XXX-XXX-XXXX format)(*)
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Home Phone
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Cell Phone
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HOME ADDRESS
Home Street/PO Address(*)
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Home City(*)
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Home State(*)
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Home Zip Code(*)
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Home County(*)
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DEMOGRAPHIC INFORMATION
Race(*)
Black or African American Asian Caucasian American Indian or Alaska Native Native Hawaiian or Pacific Islander Invalid Input
Ethnicity(*)
Hispanic or Latino Non-hispanic or Latino Invalid Input
Gender(*)
Female Male Invalid Input
Disability(*)
Yes No Invalid Input
Veteran Status(*)
Non-veteran Veteran Service-Disabled Veteran Invalid Input
COMPANY INFORMATION
Company Name(*)
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Company Street/PO Address(*)
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Company City(*)
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Company State(*)
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Company Zip Code(*)
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How long have you been in business?(*)
Less than 6 months 6 to 12 months More than a year More than 5 years Invalid Input
Date Company Established
Company County(*)
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Company Website
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Legal Structure(*)
Sole Proprietor General Partnership S-Corporation Limited Liability Company (LLC) Other Invalid Input
Company Ownership Gender(*)
Female Majority Owned Male Majority Owned 50% Female, 50% Male Owned Invalid Input
Company Ownership - Veteran Status(*)
Non-Veteran Majority Owned Veteran Majority Owned Service-Disabled Veteran Majority Owned Invalid Input
Briefly Describe Your Business including Products/Services(*)
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Is this primarily an online business?(*)
Yes No Invalid Input
Is this a home based business?(*)
Yes No Invalid Input
Do you conduct International Trade?(*)
No Import Export Both Import and Export Invalid Input
What was your gross revenue last year?(*)
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What was your net profit last year (before taxes)?(*)
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How many full time employees do you have?(*)
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How many part-time employees do you have?(*)
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NEEDS ASSESSMENT
Briefly describe how we can help you(*)
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Do you have a Business or Strategic Plan?(*)
Yes No Invalid Input
Do you have a Sales Forecast?(*)
Yes No Invalid Input
Do you have a Marketing Plan?(*)
Yes No Invalid Input
Do you have a Financial Plan?(*)
Yes No Invalid Input
Do you have a monthly comparison of actual vs budgeted financial results?(*)
Yes No Invalid Input
Are you seeking to do business with the government?(*)
Yes No Invalid Input
Are you seeking financing?(*)
Yes No Invalid Input
REQUEST CONSULTING SERVICE
Referred by(*)
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I have read the "Client's Rights and Responsibilities". I recognize that I am ultimately responsible for the success or failure of my business and that all decisions pertaining to implementing plans and operating my business are solely my responsibility. I hereby request consulting assistance and waive any claims of damages against Widener University SBDC, SBDC personnel, the Pennsylvania SBDC program, Widener University, the US Small Business Administration, and the Pennsylvania Department of Community and Economic Development, based on any advice or information provided by the SBDC.
Do you agree with the above statement?(*)
Yes No Invalid Input
Please type your full name(*)
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Please enter the numeric security code (*)
After pressing the "Submit" button, you should see a message confirming your request. If you do not see this message, please check to be sure you have completed all of the required information and have correctly entered the security code. Please contact us at 610-619-8490 if you are having any difficulty with this form.
Help with an Existing Business
