Please provide the following contact information:

Name of Company
Your Name
Street address
Address (cont.)
City
State
Zip
County
Type of Business
Business Ownership/Gender	Please Select One Male Female Male/Female
Phone
E-mail
Indicate Briefly The Nature Of Service And/Or Counseling You Are Seeking
I Accept	I request business counseling from the Small Business Administration. I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA assistance services. I authorize SBA to furnish relevant information to the assigned management counselor(s) although I expect the information to be held in strict confidence by him/her. I further understand that any counselor has agreed 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 SBA's furnishing management or technical assistance, I waive all claims against the SBA personnel, SCORE, SBDC and its host organizations, SBI, and other SBA Resource Counselors arising from this assistance.