New Client Application

Client Request for Counseling

Client Name *

First

Last

Name of person completing the form/representative of the business

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone *

Primary

Phone

Secondary

I request business counseling service from the Mission West Community Development Partners (MWCDP). I agree to cooperate should I be selected to participate in surveys designed to evaluate MWCDP services. I permit MWCDP or its agent the use of my name and address for MWCDP surveys and information mailings regarding MWCDP products and services

Yes
No

I understand that any information disclosed will be held in strict confidence. (MW will not provide your personal information to commercial entities.) I authorize MW 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 MW personnel, and that of its Resource Partners and host organizations, arising from this assistance. Please note: The estimated burden for completing this form is 18 minutes. 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, 409 3rd Street, SW, Washington, DC 20416, and to: Desk Officer LCCDC, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C., 20503. OMB Approval (3245-0324). PLEASE DO NOT SEND FORMS TO OMB.

Is your business located in the TIF (Tax Increment Finance) District?

Yes
No

Client Intake

To be completed by all clients

Race

Ethnicity

Gender

Do you consider yourself a person with a disability?

Yes
No

Veteran Status

Military Status

Member of Reserve or National Guard
On Active Duty

What prompted you to contact us?

What is the nature of counseling you are seeking?

Describe specific assistance requested in the space provided.

Are you currently in business? (If NO, skip to end)

Yes
No

Name of Company

Type of Business

% Male Owned

Selected Value: 0

% Female Owned

Selected Value: 0

Date Business Started

Do you conduct business online?

Yes
No

Are you a home based Business?

Yes
No

Are you 8(a) certified?

Yes
No

If yes, certification date

Total Number of Employees (full & part time)

For your most recent full business year, what were your Gross Revenues/Sales?

$

For your most recent full business year, what were your +Profits/-Losse

$

What is the legal entity of your business?

NAICS Code

DUNS

Business size:

Business Advisory Services Provided at No Charge to You

Because the MWCDP program is supported by the State of Montana, and our other partners this service is provided at no charge to you. Fees may apply for training programs, special services (such as research), materials, and publications. As detailed below we provide Confidentiality of Information Provided, Unbiased Recommendations, Non-Disclosure of Trade Secrets, along with Assistance, Guidance, Recommendations and Education. [Client retains one copy and LCCDC Business advisor retains one copy for file.] In order for the MWCDP to be able to continue to provide our services to you at no charge, we need from you: Your participation in surveys and requests for results – Because this program cares about the quality of services provided, and because it is primarily funded with public support, the MWCDP is required to measure the quality and impact of services provided to you. You may receive between surveys from the MWCDP every year. You as a client of the MWCDP agree to provide this information to the best of your ability. This Information will be kept confidential– All MWCDP’s representatives agree to abide by Confidentiality Agreements. Information you provide will be held in strictest confidence and will not be released to any parties outside of the MWCDP network without your specific consent. Information on you will not be sold or provided to other organizations. Information about the MWCDP’s service delivery is reported in aggregate to its funders and the general public. Specific information about you will not be released without your consent. The MWCDP will collect and report in aggregate to its funders and the general public information on you such as demographic statistics; size, location, age and industry of your business; the general nature of your engagement with the MWCDP; and impact statistics such as financing obtained, sales increased or jobs created. If you were referred to the MWCDP ,the MWCDP will notify the referrer that you have sought assistance from the MWCDP. The MWCDP, however, will not disclose in detail the nature of the assistance you are requesting, without your consent. 1. Unbiased Recommendations - MWCDP representatives will not knowingly recommend the purchase of goods or services from any individual or firm with which any MWCDP representative has a financial, familial or personal interest. 2. Sensitive trade secrets pertaining to unique facts of your business will not be used to benefit another client of the MWCDP or any MWCDP representative. You understand that sensitive trade secret information is information which is not obvious, which is unknown, or which is unique and pertains to new inventions, secret manufacturing and processing procedures or formulas, or any new innovative process. You understand that it is your responsibility to inform the MWCDP of any such sensitive trade secrets both verbally and in writing. 3. Assistance, Guidance, Recommendations and Education – The MWCDP program is an educational program. The MWCDP will work with you on your specific issues to help build your management skills and knowledge. It is your responsibility to accept and implement recommendations. The MWCDP will not: negotiate on your behalf, write your business plan, act as an employee of your business.

Accepting Responsibility and Waiving all Claims – In recognition that you are ultimately responsible for the success or failure of your business and that all decisions pertaining to implementing plans and operating your business are solely your responsibility, you hereby waive any claims of damages against the Montana MWCDP program, Montana Department of Commerce, the State of Montana, and the US Small Business Administration, based on any advice or information provided by the MWCDP. By checking this box you agree to the above statement *

I agree

Consent to Release Information – Upon completion of my project, the MWCDP can use my business as a ‘Success Story’ with funding partners, the MWCDP board or in public information releases, such as newsletters. Completion of the project will be defined as acquisition of funding, business started, jobs created or retained and expansion completed. Commercial or financial information obtained which might be competitively harmful to your business will be kept confidential on request. I hereby grant permission to the MWCDP to use information, photographs, audio and videotape and/or film about my business for public information and educational purposes. I also agree to provide information on jobs created and/or retained to support the funding for the services provided by MW. After submitting this form, I will be taken to a page that includes a Job Creation and Retention form. I will download that form and work with you to provide the information required to support the funding for your services. *

I Consent
I do not Consent

By checking this box you agree the above information is correct and reflects your business accurately. *

I agree

You’re ready to take the next steps with your business. Please take your time filling out our New Client form. We use this information for your account set up and for grant reporting purposes.

Client Request for Counseling

Client Intake

Business Advisory Services Provided at No Charge to You

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