Client Intake Form

Contact Information
Name *
Name
Personal Phone
Personal Phone
Business Phone
Business Phone
http://
Would you like to be added to BiGAUSTIN's email list?
Home Address *
Home Address
Business Address *
Business Address
If you don't have an official location yet, input your home address.
Demographics
I certify that I am a U.S. Citizen, Permanent Resident, or a Foreign National with authorization to work in the United States. *
Gender *
Ethnicity *
Race *
Check all that apply
Date of Birth *
Date of Birth
Are you married? *
Do you consider yourself a person with a disability? *
Do you currently have health care? *
Financial
Owner Household Income Information: Estimate the annual income of the household by projecting the total gross amount of income for all persons (related or not) living in the household at the time the assistance was requested. Estimated annual income shall include income from all sources of household members including social security and retirement. Income derived from the CDBG-assisted job shall not be considered in calculating estimated annual income.
Estimate if necessary
$
Are you considered the Head of Household for Income Tax purposes? *
Do you receive any of the following? *
Business Information
How long has your business been operating? *
Do you have a written business plan? *
If none, put N/A
Business Start Date *
Business Start Date
If you don't have an official start date, estimate when you first had the idea of starting a business.
Is your business City-Certified? *
If yes, please choose which applies to you
Where is your business located? *
Are you currently exporting? *
Which does your business currently provide? *
Are you the Sole Proprietor? *
If yes, please answer the following two questions below.
If yes, please choose which applies
$
$
$
Veteran Status
The applicant is a Veteran under the following criteria: "Any former member of the armed forces who was discharged or released from duty under any conditions other than dishonorable, as well as active and former members of the Reserve, National Guard, and active duty military members preparing to transition to civilian life."
Are you a Veteran? *
If yes, please answer prospective questions.
Are you a Veteran with over 179 days of active duty?
Are you a Vietnam Veteran?
Status
Disability
By checking below, the applicant hereby swears or affirms that all information contained herein is true and that the applicant will abide by all the requirements and regulations of TVC educational programs. *
Initial Interest
What are you interested in acquiring from BiGAUSTIN? *
Check all that apply
What training are you interested in acquiring from BiGAUSTIN? *
Check all that apply
How did you hear about BiGAUSTIN? *
Check all that apply
What general areas would you like business counseling with? *
Check all that apply
SBA Disclaimer
I request business management counseling service from a Small Business Administration Partner. I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA assistance services. I further agree to be included in this SBA partner’s email distribution list and that upon receipt of email communications I will be given the opportunity to unsubscribe. I authorize SBA to furnish relevant information to the assigned management counselor(s). I understand that any information disclosed to 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 the counselor(s) furnishing management of technical assistance, I waive all claims against SBA personnel, BiGAUSTIN 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 are not required to respond to any collection information unless it displays a currently valid OMB approval number. Comments on the burden should be sent to U.S. Small Business Administration, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503. OMB Approval (3245-0091) PLEASE DO NOT SEND FORMS TO OMB.
City of Austin Owner Disclaimer *
Evidenced by checking below, Owner certifies his or her annual household income. Owner certifies that the information herein provided is true and accurate. Owner further acknowledges that any inaccuracy and/or misrepresentation provided herein may constitute fraud, which is punishable by law. Owner certifies that all information herein and any attachments hereto, are true and correct as of the date set forth opposite signature. Owner acknowledges that Title 18, Section 1001 of the US Code states that any person that makes intentional or negligent statements to any department of the United States Government is guilty of a felony that could result in but not be limited to a fine, imprisonment, or both. This activity is funded with federal Community Development Block Grant (CDBG) funds and is designed to primarily benefit low to moderate-income households (LMI) through the provision of assistance to micro-enterprises under 24 CFR 570.201(o). A micro-enterprise is a business that has no more than 5 employees, of which, one is the owner. The microenterprise business owner must also be an income eligible household in order to meet the federal micro-enterprise definition and participate in the program. Owner should not provide his/her signature unless he/she has read and understands the income information they are certifying under penalty of law. At the discretion of the program, Owner may be required to provide documentation to the Program to confirm the self-declaration of income.