Please correct these errors, then click the Submit button
These fields are marked in red below:
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
Dr. Mr. Mrs. Ms.
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
{Select One} Female Male No Reply
Veteran Status
{Select One} Non-Veteran Veteran Srvc-Cnnctd Dsbld Vet. No Reply
Are you a person with a Disability?
{Select One} No Yes No Reply
Military Status
Not Military Reserve/National Guard On Active Duty
Race
Are you of Hispanic origin?
{Select One} No Yes No Reply Are you 8(a) Certified?
{Select One} No Yes
Business Profile
Are you currently in business?
{Select One} In Business Not in Business Stage of development
{Select One} Thinking (idea) Launching (startup) Growing (established) Reinventing (turnaround) Exiting (cashout) Describe your business or idea
(in 3 to 5 words)
Annual Sales
Annual Profit or Loss
Oregon Business Identification Number
Areas of Interest
What kind of assistance do you seek?
Check all that apply (but at least one, please)
What prompted you to contact us?
Check all that apply (but at least one, please)
Assistance Required
Immediate assistance: Choose one or the other
The BizCenter nearest you:
Choose for me
Albany
Baker City
Central Oregon
Clackamas
Coos Bay/North Bend
Enterprise
Eugene
Grants Pass
Gresham
Hermiston
Klamath Falls
La Grande
Lincoln City
Medford
Nehalem
Pacific City
Pendleton
Portland
Roseburg
Salem
Seaside
The Dalles
Tillamook
Treasure Valley
International Trade Assistance
Check all that apply (but at least one, please)
In the meantime: Check all that apply (but at least one, please)
Referral Information
Who referred you to the BizCenter?
Self
SBDC Client
SBDC Counselor
Legislator
Other
Electronic Signature
Type “I Accept” (without the quotation marks)
Application Date
Password Reminder
Question to ask if you forget your password
{Select One} What is the city of your birth? What is the name of your favorite pet? What is the name of your first cousin? What is your birthdate (in MM-DD-YYYY format) ? What is your favorite restaurant? What is your favorite rock band?
Your answer to the password reminder question
(one word only, if possible)
SBA Form 641 Federal Regulation - OMB Approval No. 3245-0324
