Client Registration

Click here to register with our secure form instead.

Registration Instructions
To qualify for counseling assistance, please provide the information below. Required fields are marked with an asterisk When you’ve completed the form, click the “Submit this Registration” button at the bottom of this page.
Contact Information
Prefix / First Name
Last Name
Email (name@work.com)
Position/Title (CEO, Owner, President, etc.)
Website (if your company has one)
Business Name (if known)
Business Phone in format: (nnn) nnn-nnnn
Address 1
Business Fax in format: (nnn) nnn-nnnn
Address 2
Home Phone in format: (nnn) nnn-nnnn
City & State
,
Cell Phone in format: (nnn) nnn-nnnn
Zipcode (+ 4 if known)
+
Date of Birth in format: YYYY-MM-DD
Demographic Profile
Because our program is federally funded, we are required to track client demographic data. Please choose the descriptions which most closely apply to you.
Gender
Veteran Status
Are you a person with a Disability?
Military Status
Race
Asian
Black
Native American/Alaska Native
Native Hawaiian/Pacific Islander
No Race Response
White
Are you of Hispanic origin?
Are you 8(a) Certified?
Business Profile
Are you currently in business?
Stage of development
Describe your business or idea
(in 3 to 5 words)
Annual Sales
Annual Profit or Loss
Oregon Business Identification Number
If already in Business...
Legal structure of business
Date the business started
(MM/DD/YYYY)
Female ownership (0 to 100%)
%
How many part-time employees do you currently have?
(please count owners)
How many full-time employees do you currently have?
Special business location:
Business Online
Home Based Business
Areas of Interest
What kind of assistance do you seek? Check all that apply (but at least one, please)

Business Plan
Buy/Sell a Business
Capital Sources
Financial
Franchises
Human Resources
International Trade
Marketing/Sales
Start-ups
Technology

Other  
What prompted you to contact us? Check all that apply (but at least one, please)

Business Owner
Chamber of Commerce
Educational Institution
Internet
Lender
Local Economic Development Official
Magazine
Newspaper
Other Client
SBA District
SBA Web site
Television / Radio
Word of Mouth

  
Assistance Required
Immediate assistance: Choose one or the other

Contact me to schedule a counseling session
I have made an appointment for counseling and have been instructed by my local SBDC to pre-register
I'm just browsing

In the meantime: Check all that apply (but at least one, please)

Send me a Workshop Recommendation
Send me a Resource Recommendation
Add me to your email list
Referral Information

Who referred you to the BizCenter?
 
Electronic Signature

“I request business management counseling from the Oregon Small Business Development Center (BizCenter). I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA or BizCenter assistance services. I understand that any information received by an BizCenter business advisor will be held in strict confidence by the advisor to the extent allowable by law.”

“I further understand that any business advisor has agreed: (1) not to recommend goods or services from sources in which he/she has an interest, nor (2) accept fees or commissions developing from this relationship. In consideration of BizCenter’s furnishing management or technical assistance, I agree to waive all claims against the Oregon SBDC BizCenter, its personnel, its host organizations (Oregon community colleges), SCORE, and other SBA Business Advisors arising from this assistance.”

“I, , accept this Agreement by typing I Accept as my electronic signature.”
Type “I Accept” (without the quotation marks)
Application Date
Password Reminder

Question to ask if you forget your password
Your answer to the password reminder question
(one word only, if possible)






SBA Form 641 Federal Regulation - OMB Approval No. 3245-0324