1. Name of Company:
2. Your Name(Last,First,Middle):
4. Street Address: *Required
9. Governmental Information
W hat elected official represents the area where you conduct
(This information can be filled out when you meet with
10. Ethnic Background:
: 11. Veteran Status
: 12. Business Ownership Gender
13. SBA Relationship:
A. Have you ever applied for a SBA loan?
B. Did you receive a SBA loan?
If yes, amount? $
: 14. Company Information
Former SBDC client?
No SIC Code (if known)
15. Are you presently?
Starting a new business
Buying an existing business
Already in business
16. If in business, is the company
(circle best description below)
: 17. Present No. of Employees
of Full-Time Number
: 18. Type of Business
19. Form of Business :
20. How did you learn of our services?
21. Check the area of desired assistance:
22. Please describe how the SBDC
may be of assistance: *Required
The Statement Below
(You will be asked to sign this document
when you meet with a counselor.)
I request management assistance from the Small Business Administration
and/or the Small Business Development Center. I understand this assistance
is free of charge. I agree to notify my elected officials of the impact
of this service to the small business community and to cooperate should
I be selected to participate in surveys designed to evaluate SBA/SBDC
assistance services. I authorize SBA/SBDC to furnish information to the
assigned management counselor although I expect that information to be
held in strict confidence by the counselor.
I further understand that nay counselor has agreed not to (1) recommend
goods or services from sources in which the counselor has an interest,
and (2) accept fees or commissions developing from this counseling relationship.
In consideration of SBA's furnishing management or technical assistance,
I waive all claims against SBA personnel, SCORE, SBDC, and host organizations,
SBI and other SBA Resource Counselors arising from this assistance.
Signature and Title of Requestor