Request for Consulting

Personal Information
  Items with an asterisk (*) are required.
Name of Company
Last Name*
First Name* Middle Intitial
Telephone*
Fax
Cell
E-mail
Street Address*
City*
State* Postal Code*
County*
Governmental Information
Which elected official represents the area where you conduct business?
 (This information can be filled out when you meet with a counselor.)
 
District No.
Name
State House Representative
State Senator
U.S. Representative
U.S. Senator
Background Information
Race/Ethnic Background
Veteran Status
Business Ownership Gender
Company Information
Have you ever applied for an SBA loan? Did you receive an SBA loan? If yes, amount? $
Former SBDC client? SIC Code (if known) Annual Gross Sales $
Are you presently? month/year started /
If in business, is the company? (select best description)
Present Number of Full-Time Employees Present Number of Part-Time Employees
Type of Business Other
Form of Business Other
Other Information
How did you learn of our services? Accountant
Legal Counselor
Bank
Chamber of Commerce
Media—TV/Radio
Seminar
Client Word of Mouth
Newspaper
Yellow Pages
SBA
Government Agency
Other
 Check the area of desired assistance. Starting a New Business
Accounting and Records
Patents
Source of Capital
Financial Analysis
Marketing/Sales
Product Development
Government Procurement
Environmental
Energy Efficiency
Other
Please describe how the SBDC may be of assistance.
Agreement

Please Read the Statement Below
(You will be asked to sign this document when you meet with a counselor.)

I request business management assistance from the Small Business Administration (SBA) and/or the Small Business Development Center of The Pennsylvania State University (SBDC). 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/resource counselor(s), although I expect that information to be held in strict confidence by the counselor.

I further understand that all counselors have agreed not to (1) recommend goods or services from sources in which they have an interest and (2) accept fees or commissions developing from this counseling relationship.

In consideration of the SBA’s/SBDC’s furnishing of management or technical assistance, I waive all present and future claims of whatever nature against The Pennsylvania State University, SBA personnel, SCORE, SBDC and host organizations, SBI, and other SBA/SBDC management/resource counselors arising from this assistance.

I understand that there are no warranties or assurances in connection with the counseling assistance. The Pennsylvania State University is an equal opportunity university.  

Electronic Signature: (enter your name) Date (mm/dd/yyyy)

By means of an electronic signature, I understand I am agreeing to the terms listed above.