NETWORK ACCESS SURVEY

WE ARE ALWAYS STRIVING TO PROVIDE THE SMALL BUSINESS OWNER WITH THE INFORMATION, BENEFITS,
OR ASSISTANCE NEEDED. PLEASE TAKE THE TIME TO FILL OUT THIS SURVEY FORM SO THAT WE
MAY BE BETTER ABLE TO SERVE YOU. WHICH OF THE FOLLOWING PROGRAMS ARE
YOU INTERESTED IN? (please print this form and check all that apply)
See mailing instructions at the bottom of this survey.

FINANCIAL REFERRAL NETWORK FINANCIAL REFERRAL NETWORK
Amount of loan/credit line sought $__________
Do you own real estate? YES YES   NO NO
  If yes, how much equity do you have? $__________
How long has your business been established? __________ years

BUSINESS COUNSELING 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 MEDICAL/DENTAL & BENEFITS PACKAGE REFERRAL
Number of employees __________ Average age of employees __________
Are you interested in medical insurance? YES YES   NO NO
Are you interested in dental insurance? YES YES   NO NO
Are you interested in life insurance? YES YES   NO NO
Are you interested in disability insurance? YES YES   NO NO

INTERNET BASED PAYROLL & HUMAN RESOURCES SERVICES INTERNET BASED PAYROLL & HUMAN RESOURCES SERVICES
Are you interested in internet based payroll services? YES YES   NO NO
Are you interested in other human resources services? YES YES   NO NO

BUSINESS SEMINARS AND WORKSHOPS BUSINESS SEMINARS AND WORKSHOPS
What business seminar/workshop topics interest you?
I am interested in: _______________________________________________________

OTHER SMALL BUSINESS SERVICES OR INFORMATION 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

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Small Business Assistance Center
119 E. Locust Lane • Kennett Square, Pa 19348 USA • Fax (610) 444-1724