Filling out Form 641 is necessary in order for the American Samoa Small Business
Development Center (SBDC) to provide free, one-on-one, confidential counseling to
However, filling out Form 641 does not guarantee that the
American Samoa SBDC will provide such
counseling. A consultant for the SBDC will make a decision as to whether or not
to engage in a consulting relationship based upon their available time and their
ability to be of assistance to you.
In order for them to make this decision, you may be asked for additional information.
** = required information
a.Native American or Alaskan Native
c.Black or African American
d.Native Hawaiian or other Pacific Islander
b.Not of Hispanic Origin
a. Aid to Families with Dependent ChildrenYes
b. Temporary Assistance to Needy FamiliesYes
b.Service Connected Disabled Veteran
c.Vietnam Era Veteran
a.Word of Mouth
d.Chamber of Commerce
Is this a home based business?
NOTICE: BY SUBMITTING THIS FORM, YOU ARE AGREEING TO THE FOLLOWING:
I request business management counseling service from a Small Business Administration
Resource Partner. I agree to cooperate should I be selected to participate in surveys
designated to evaluate SBA assistance services. I authorize SBA to furnish relevant
information to the assigned management counselor(s). I understand that any information
disclosed will 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 for the counselor(s) furnishing management or technical assistance,
I waive all claims against SBA personnel, SCORE and its hostorganizations, and other
SBA Resource Counselors arising from this assistance.
Funded in part through a Cooperative Agreement with the U.S. Small Business Administration.
The American Samoa Small Business Development Center was created as result of an
American Samoa Community College (ASCC) and U.S. Small Business Administration (SBA)
Partnership. Neither SBA funding nor that from ASCC is an endorsement of any
products, opinions or services. SBA and ASCC Programs are extended to the
public on a non-discriminatory basis.