SBDC Consulting Request

Business Size:

Business Type:

Organization Type:

Ethnic Group:

Military Status:

SBA Relationship:

In the last two years, have you ever received?

Aid to Families with Dependent Children (AFDC) Yes No

Temporary Assistance to Needy Families (TANF) Yes No

Check the problem areas for which you seek assistance:

Sales Volume:

How did you learn of these counseling services :

Number of employees:

Status:

Brief description of business:

Legislators:

I request management assistance from the Small Business Development Center. 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 that information to be held in strict confidence by him or 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 SBA personnel, SCORE, SBDC and the University of Pittsburgh, SBI, and other SBA Resource Counselors arising from this assistance. Please note: The estimated burden for completing this form is 15 minutes per response. You will not be required to respond to this information collection if a valid OMB approval number is not displayed. If you have questions or comments concerning this estimate or other aspects of this information, please contact the U.S. Small Business Administration, Chief, Administrative Information Branch,
Washington, DC 20416 and/or Office of Management and Budget, clearance Officer, Paperwork Reduction Project .