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BC Form No.1 Rev0

BUSINESS COUNSELING FORM

I hereby consent to the collection and processing by the DTI of my name, contact, details on its services for the
purpose of monitoring, measuring, analyzing business counseling service and of improving DTI services. I shall
notify DTI in any case of any changes in my personal information. This consent shall be valid, unless revoked or
withdrawn in writing subject to the applicable provisions of the Data Privacy Act of 2012 or Republic Act no.
10173.

I further certify that the information provided below is true and correct.

Client's Signature Date & Time

Section I. To be filled up by Client

Complete Name:
(Title/Prefix) (First) (Middle) (Last) (Suffix)
Designation (if applicable):
Social Classification: ☐ Abled ☐ PWD ☐ 4Ps ☐ OFW Sex:
☐ Indigenous Person ☐Senior Citizen ☐ Youth ☐ Others: ___________ ☐ Male ☐ Female

Business Status: ☐ Unregistered ☐ Registered

Name of Business:
Address:
(House/Bdlg No./Bldg Name) (Street) (Barangay)

(City/Municipality) (Province) (Region) (Zip Code)

Contact Details
Tel. Number: Mobile Number:
E-mail: Fax:
Details of Request/Query:

Section II. To be filled-out by the Business Counselor

EDT Level: ☐ Level 0: Potential ☐ Level 1: Start-up ☐ Level 1.1 Not Registered
☐ Level 1.2 Partially Registered ☐ Level 2 Growing Enterprise;
☐ Level 3 Expanding Enterprise; ☐ Level 4 Sustaining Enterprise
Industry Classification:
Product Line/Services:
Form of Organization: ☐ Sole Proprietorship ☐Partnership ☐Corporation ☐Cooperative
☐ Others: _________
Asset Size (in Philippine Pesos): Total No. of
☐₱3M and below ☐ Above ₱3M up to ₱15M Employees:
☐Above ₱15M up to ₱100M ☐Above ₱100M

Counseling on:
☐ Marketing ☐ Human Resource ☐ Training
☐ Finance ☐ Production ☐ Others, pls. specify:

Action Taken/Agreements: ☐ Provided with ☐ Not Provided

Information

Referred to:
DTI Office/Bureau/Division
Coach/Mentor
Other agency/ies

Time Counseling started: _______

Time Counseling ended: _______
Name & Signature of
Total Counseling time: _______ DTI-Business Counselor