Request for Consulting

Pontotoc Technology Center

A secondary location of Small Business Development

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Please answer the following questions regarding your existing or planned business.

First Name
Last Name
Zip Code	Enter your 5 digit Zip Code. If you don't have one or don't know your zip code, enter 00000

Please enter the following information so that we may contact you if necessary.

Primary Phone	The best phone number (with area code) to reach you during standard business hours. Include extension if necessary.
Primary Phone Type	Type of the primary phone above
Secondary Phone	A secondary phone number to contact you, if we cannot reach you at the primary number.
Secondary Phone Type	Type of the secondary phone above

Please answer the following demographic questions.

Race	Asian Black or African American Native American/Alaska Native Native Hawaiian/Pacific Islander White Prefer not to say Check any that apply
Choctaw Tribal Member	Yes If you are currently a Choctaw Tribal Member
Ten & 1/2 Counties	Yes If you reside within the following counties: Atoka, Bryan, Choctaw, Coal, Haskell, Hughes, Latimer, LeFlore, McCurtain, Pittsburg, Pushmataha.
Tribal District	Click Here to find your Choctaw Tribal district. Do not close this browser session. Choose 'Out of District' if you do not live in a tribal district.
Date of Birth	Required for Choctaw Nation support services
Hispanic Ethnicity
Gender
Person with Disability	Do you consider yourself a person with a disability
Military Status
Military Status (OBSOLETE)

Business Status

Business has started

Check if you have started conducting business. Leave unchecked if you are in the planning stages and have yet to start your business.

Business Name	Leave blank if you do not have a name chosen or the business name is the same as your name.
Position	Your position or title related to this business

Address

Your physical street address (number and street) of the business. If a home based business, or the business has not started yet, use your home address.

Address Line 2

Optional. Use if you need additional address postal information like apt, floor, suite, etc., or a PO box.

City

State

Web Site	Web site URL for the business
Business Description	Brief three to five word description of the business
Registered Business	Yes If your business is currently registered with the state

Please provide the following information to help us assess your business concept.

Registered Business	Yes If your business is already registered with the state
Business Plan	Yes If you have written a business plan
Financial Projections	Yes If you already have formulated financial projections
6 Hours of Business Training	Yes If you have completed 6 or more hours of buisiness training

Since this business has started, please enter the following information.

Year Started	Year this business started
Month Started	Month this business started
Industry	Primary category of business
Business Plan	Yes If you have written a business plan
Financial Projections	Yes If you have financial projections
Female Ownership %	% Enter the percent female ownership for this business.
Business Online	Yes If business is conducted online
Home Based Business	Yes If business is home based
8(a) Certified	Yes If you are currently 8(a) certified.

Business Organization

Legal entity of the business

Employees FT

Current Number of Full Time Employees

Employees PT

Current Number of Part Time Employees

Annual Sales $

Annual Sales $ for the most recent full business year

Annual P/L $

Annual Profit/Loss $ for the most recent full business year

Are you currently exporting

Yes

Export Employees	Current Number of Total Export Related Employees
Export Sales $	Export Related Sales for most recent full business year
Export Countries	Countries you are currently exporting to. Start typing the name of the country and a list will appear to choose from. You may select more than one.

How did you hear about us?
Assistance Requested	Business Accounting/Budget Business Plan Buy/Sell a Business Cash Flow Management Customer Relations eCommerce Financing/Capital Franchising Government Contracting Human Resources/Employees International Trade Legal Issues Managing Business Marketing/Sales Start-up Assistance Tax Planning Technology/Computers Check all the kinds of assistance that you seek
Briefly describe the specific assistance you are requesting or goals you want to achieve

Please read the following, enter your Full Name, and click Continue below to indicate your acceptance.

I request business counseling service from the Choctaw Nation of Oklahoma or their Resource Partner. I agree to cooperate should I be selected to participate in surveys designed to evaluate Choctaw Nation of Oklahoma services.

I permit Choctaw Nation of Oklahoma or its agent the use of my name and address for surveys and information mailings regarding products and services

I understand that any information disclosed will be held in strict confidence. (Choctaw Nation of Oklahoma will not provide your personal information to commercial entities.) I authorize Choctaw Nation to furnish relevant information to the assigned management counselor(s). I further understand that the counselor(s) agrees 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 of the counselor(s) furnishing management or technical assistance, I waive all claims against Choctaw Nation of Oklahoma, and that of its Resource Partners, arising from this assistance.

Please enter your full name, indicating your acceptance of the above terms.

Full Name:

Date: 5/5/2024 6:27:39 PM

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