Business Solutions Ctr. Coaching Agreement Form

The Businesss Solutions Center at Eastern Illinois University helps entrepreneurs and businesses reach their full potential. If you would like to have our business coach contact you to set up free and confidential business coaching, please complete the form below (takes approximately 3 - 5 minutes) and we will get back to you promptly.

Name * First Last
Phone * - (###) - ### ####
Email Address *
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
County *
DISCLAIMER:
I request business/management counseling from the Business Solutions Center at Eastern Illinois University (BSC). I understand that any information received by a Business Solutions Center staff member will be held in strict confidence to the extent permitted by law. I further understand that BSC staff has agreed not to: (1) recommend goods or services from sources in which the individual counselor has an interest; and (2) accept fees or commissions developing from any business \coaching. In consideration of the provision of management and/or technical assistance by the BSC coach(es) & staff, I agree to waive any and all direct or indirect claims arising out of this assistance and indemnify and hold harmless BSC personnel and the Board of Trustees of Eastern Illinois University, the State of Illinois, from any and all claims arising from the coach’s advice and/or assistance.
Counseling Request and Agreement * By checking, I agree to the disclaimer
Enter initials to confirm agreement *

Type in your initials to confirm you have read our disclaimer.
Date * / MM / DD YYYY
Client Intake (to be completed by all Clients)
1. Race (mark one or more) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White
2. Ethnicity Hispanic or Latino Not Hispanic or Latino
3. Gender Female Male
4. Do you consider yourself a person with a disability? Yes No
5. Veteran Status Non-Veteran Veteran Service-Disabled Veteran
5a. Military Status Member of Reserve or National Guard On Active Duty
6. What prompted you to contact us? (mark all that apply) BSC Website Lender Business Owner TV / Radio Internet Newspaper Other Client Educational Institution Word of Mouth Chamber of Commerce
Other (specify)
7. Are you currently in business? Yes No (if No, skip to 17)
8. Name of Company
9. Type of Business (choose primary catagory) Mining Utilities Information Construction Retail Trade Manufacturing Finance & Insurance Wholesale Trade Public Administration Educational Services Real Estate & Rental/Leasing Health Care and Social Assistance Hospitality / Food Services Arts, Entertainment & Recreation Transportation and Warehousing Professional / Scientific / Technical Services Management of Companies and Enterprises Agriculture / Forestry / Fishing / Hunting Administrative and Support Waste Management & Remediation Services
Other (except Public Administration)
10. Business Ownership - What percentage of your business is male or female ownership?
% Male % Female
11. Month and Year Business Started? / MM / DD YYYY
12. Do you conduct business online? Yes No
13. Are you a home based business? Yes No
14. Total number of employees (full & part-time)
15. For your most recent full business year, what were your:
Gross Revenues/Sales:$ +Profits / -Losses:$
16. What is the legal entity of your business? Sole Proprietorship S-Corporation Corporation Partnership LLC
Other (specify)
17. What is the nature of coaching that you are seeking? (Choose primary category) Start-up Assistance (How do I start a small business?) Business Plan Financing / Capital (such as applying for a loan, building equity capital? Managing a business Human Resources / Managing Employees Customer Relations Business Accounting / Budget Cash Flow Management Tax Planning Marketing / Sales (promotion, market research, pricing, etc.) Government Contracting (including certifications) Franchising Buy / Sell Business Technology / Computers eCommerce (using the internet to do business) Legal Issues (i.e. Should I incorporate?) International Trade
Describe specific assistance requested in the space provided: *
Free and confidential counseling is NOT contingent upon your voluntary agreement the the items below.
I understand that the BSC may use my name, company name, testimonial and likeness in promotion materials to market the services that the BSC offers. * Yes No
I understand that the BSC may use impact information to measure the BSC’s coaching effectiveness. This information is reported in aggregate with all other entities coached and helps justify the funding of our free services to various public and private funders. If impacts are achieved due to the coaching received from the Business Solutions Center at Eastern Illinois University, I agree to allow them to be reported. * Yes No
I would like to be added to the BSC contact list so I receive information regarding initiatives of the BSC and their bi-monthly Entrepreneurial Endeavors e-blast newsletter. (Information will be kept confidential and is not distributed or shared with any 3rd party provider.) * Yes No Already receive e-blast newsletter
Initial *
How were you referred to us?

Business Solutions Ctr. Coaching Agreement Form

Business Solutions Ctr. Coaching Agreement Form

Client Intake (to be completed by all Clients)

Free and confidential counseling is NOT contingent upon your voluntary agreement the the items below.