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Request for Counseling









Home Address*


(Optional)





Business Address

(If applicable)


(Optional)





14. Race
        
15. Ethnicity
        
16. Gender
        
17. Do you consider yourself a person with a disability?
        
18a. Veteran Status
        
18b. Military Status

(If applicable)

        
19. Referred by (Mark all that apply)
  1. (Please indicate website below)
  2. (Please indicate below)
        



20a. Are you currently in business?* (If no, skip to 30)
        
20b. Do you have a business website?
        


21. Are you currently exporting?
        


23. Business Ownership Percentages (Enter the number only)

%

%
24. Date Business Started


,

25. Do you conduct business online?
        
26a. Are you a home-based business?
        
26b. If a home-based business, are you 8(a) certified?
        
27. Total Number of Employees (Enter the number only)


28a. For your most recent full business year, what were your

$ .00

(if applicable)
+$ .00

(if applicable)
-$ .00


$ .00





 


 

33. Terms and Conditions Agreement

I request business counseling service from the Small Business Administration (SBA) or an SBA Resource Partner. I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA services. I permit SBA or its agent the use of my name and address for SBA surveys and information mailings regarding SBA products and services. I understand that any information disclosed will be held in strict confidence. (SBA will not provide your personal information to commercial entities.) I authorize SBA 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 SBA personnel, and that of its Resource Partners and host organizations, arising from this assistance.

SBDC services are not available to individuals or entities that have been debarred or suspended by the federal government. By agreeing to receive assistance from the SBDC, you are self-certifying that you are not currently federally debarred or suspended and also agree to cease using SBDC services if you become federally debarred or suspended in the future.

34. By checking this box, you agree to the SBA terms and conditions of this document and PREP waiver.

        

  • Small Business Development Center
  • Eberly College of Business and Information Technology
    Room 108
    664 Pratt Drive
    Indiana, PA 15705
  • Phone: 724-357-7915
  • Fax: 724-357-5985
  • Office Hours
  • Monday through Friday
  • 8:00 a.m. – 12:00 p.m.
  • 1:00 p.m. – 4:30 p.m.