Request for Counseling Form

U.S. Small Business Administration Counseling Information Form

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

I request business counseling services 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. *

Yes No

I understand that any information disclosed will be held in strict confidence. (SBA will not provide your presonal 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:

recommend goods or services from sources in which he/she has an interest, and
accept fees for 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.

Use of Information: The information in this form is to be provided by individuals and business seeking technical assistance services from the Small Business Administration (SBA) or an SBA Resource Partner. The information is collected to help SBA's continuing improvement of business counseling programs, to ensure effective oversight and management of entrepreneurial development programs and grants, and to meet Congressional and Executive Branch reporting requirements. The form should be submitted at the site of service to the counselor providing the service. Resource Partners will submit information to SBA according to the terms of their notice of award.

Preferred date & time for appointment *

Client Signature *

Date *

Submit