Small Business Assistance Network Access Survey FINANCIAL REFERRAL NETWORK Amount of loan/credit line sought $_______________ Do you own real estate? YES   NO   If yes, how much equity do you have? $______________ How long has your business been established? __________ years BUSINESS COUNSELING Please list the area of expertise in which you need business counseling (i.e., start up, marketing, benefits, investing, tax, legal, etc.) _____________________________________________ _____________________________________________ MEDICAL/DENTAL & BENEFITS PACKAGE REFERRAL Number of employees __________ Average age of employees __________ Are you interested in medical insurance? YES   NO Are you interested in dental insurance? YES   NO Are you interested in life insurance? YES   NO Are you interested in disability insurance? YES   NO INTERNET BASED PAYROLL & HUMAN RESOURCES SERVICES Are you interested in internet based payroll services? YES   NO Are you interested in other human resources services? YES   NO BUSINESS SEMINARS AND WORKSHOPS What business seminar/workshop topics interest you? I am interested in: _______________________________________________________ OTHER SMALL BUSINESS PRODUCTS, SERVICES OR INFORMATION I am interested in: _______________________________________________________ I am interested in: _______________________________________________________ COMPANY/INDIVIDUAL NAME ADDRESS CITY STATE ZIP CODE TELEPHONE FAX CONTACT PERSON EMAIL HOW LONG HAVE YOU BEEN IN BUSINESS? Fax, mail or email this form to us! inquire@sbacnetwork.org

Small Business Assistance Center • 116 Saint Andrews Drive, Avondale, PA 19311