Register for Counseling

Wilmington Alliance

A secondary location of DE Navigator Hub

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Please answer the following questions regarding your existing or planned business.

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
Minority Ownership %	% Enter the expected (if preventure) or existing minority ownership percent for this business. (A business is minority-owned if at least 51% or greater of the business or stock is owned by minority individuals and the management and daily operations are controlled by one or more minorities.)
Woman Ownership %	% Enter the expected (if preventure) or existing woman ownership percent for this business. (A business is woman-owned if at least 51% or greater of the business or stock is owned by one or more women and the management and daily operations are controlled by one or more women.)

Business Name	Leave blank if you do not have a name chosen or the business name is the same as your name.
Position Title	Your position title in this business
Position Type	Your relation to this business
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 for 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, or the primary owner if there are multiple business owners. Providing the information in this section is voluntary but will be used by SBA to assess how well the program is serving different communities and to ensure equitable treatment of all people.

Check Yes if you identify as a racial minority

Yes

Check if you identify as African-American/Black, American Indian/Alaska Native, Asian, or Native Hawaiian/Pacific Islander. Leave unchecked if you are not or do not want to share information about your race.

Similar to the U.S. Census Bureau, check any races that apply.

Race	White Black Asian Native American/Alaskan Hawaiian/Pacific Check any that apply

Hispanic Ethnicity

Gender

Do you identify as

Person with Disability

Do you consider yourself a person with a disability

Veteran/Military Status

I need counseling services in a language other than English

If Yes, select a language? If English is OK, select 'Does Not Apply'

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

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.

Past SBA Services Received

If you applied for or received any of these SBA services in last 5 years, please check all that apply:

SBA 504 Loan

SBA 7(a) loan

SBA 8(a) Certification

SBA Contracting Certification

SBA Covid Economic Injury Disaster Loan (EIDL)

SBA Export Loan

SBA Microloan

SBA Other SBA Disaster Loan

SBA Paycheck Protection Loan/Forgiveness (PPP)

SBA Restaurant Revitalization Fund

SBA Shuttered Venues Grant

Check any SBA Services received above in the last 5 years, if applicable.

If referred by a specific person, bank or organization, please write here.
If you are requesting a specific Business Advisor, enter Advisor name here.
How did you hear about us?
Do you conduct business in a language other than English?	If yes, which language?
For assistance you are now seeking, please check all that apply	Business Start-up Assistance Buy/Sell a Business Cybersecurity eCommerce Financing/Capital Government Contracting Human Resources/Employees International Trade Managing Business Marketing/Sales SBA 504 Loan SBA 7(a) loan SBA 8(a) Certification SBA Contracting Certification SBA Covid Economic Injury Disaster Loan (EIDL) SBA Export Loan SBA Microloan SBA Paycheck Protection Loan/Forgiveness (PPP) SBA Restaurant Revitalization Fund SBA Shuttered Venues Grant State/Local Grants Check all the kinds of assistance above that you now seek
Briefly describe the specific assistance you are requesting
What is the dollar ($) amount of the loan or grant you are requesting, if applicable?

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

I request business counseling service from the Small Business Development Center (SBDC) or Community Navigator. I agree to cooperate should I be selected to participate in surveys designed to evaluate SBDC Navigator/SBA services.

I authorize SBDC to furnish relevant information to the assigned management counselor(s). I further understand that the counselor(s) agrees 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 the counselor(s) furnishing management or technical assistance, I waive all claims against SBDC/SBA personnel, and that of its Community Navigator and host organizations, arising from this assistance.

I self-certify that neither I nor my company are currently in suspension or debarment by a Federal Agency.

OPTIONAL: I permit SBA or its agent the use of my name and address for SBA surveys and information mailings regarding SBA products and services. I understand that any information disclosed will be held in strict confidence. (SBA will not provide your personal information to commercial entities.)

Please enter your full name, indicating your acceptance of the above terms.

Full Name:

Date: 6/4/2023 4:11:53 PM

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