Small Business Counseling Request Form - NYS SBDC

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Request for Counseling Form

Please note: The information gathered from this form is used only by Small Business Development Center staff and is NOT made public.

A. Contact information: (Required)

First Name:
Last Name:
Address:
Address:
City:
State/Province:		Zip:
Country
Website Address:
E-Mail Address:
Phone Numbers:	Example 518-555-5555
Home:		Business:
Fax:		Cellular:

B. Demographic information: (Optional)

How did you hear of us?
Race:
Ethnicity:
Business Owner Gender:
Veteran Status:
Are you disabled:	Yes No
Current Income Bracket:
Within the last 2 years have you ever received:	(Check one only) AFOC: Yes NO TANF: Yes NO

C. Business information: (Required)

Currently in Business?	Yes No (If no, skip to section D)
Sales Volume:
Profit Level/yr. %of Sales:
Name of Business:
State in which business operates:
How long in business?	years.
Business State:
Business Form:
SBA Client (Past or Present):
Exporter:
Is this a Home-based Business?	Yes No
Describe your business:

D. Request for counseling information: (Required)
Describe the nature of the counseling you are seeking

Best time for contact:

E. New York State Small Business Development Center Client Disclaimer (Required)

I request management assistance from The New York State Small Business Development Center. I understand that this assistance is free of charge and that I incur no obligation to The New York State SBDC or the U.S. Small Business Administration or its counselors for providing this assistance. I agree to cooperate should I be selected to participate in surveys designed to evaluate assistance services. I authorize the NYS/SBDC to furnish relevant information to the assigned management counselor(s) although I expect that information to be held in strict confidence to the extent allowable by law.

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 the SBDC, in cooperation with the SBA furnishing management or technical assistance, I waive all claims against The New York State SBDC, SBA, personnel or counselors arising from this assistance.

I have read the Client Disclaimer and agree to the terms and conditions stated.

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NYS Small Business Development Center
State University Plaza
Corporate Woods Building, 3rd Floor
Albany, NY 12246
In NY State (800) 732-SBDC
Outside NY State (518) 443-5398

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Partnership Program with the SBA, administered by the State University of New York. This Cooperative Agreement is partially funded by the U.S. Small Business Administration. SBA’s funding is not an endorsement of any products, opinions, or services. All SBA funded programs are extended to the public on a nondiscriminatory basis.