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Updated information for Request for Consulting
Updated information for Request for Consulting
Part I: Client Request for Counseling
Name
*
First
Last
Email
*
Primary Phone
*
Address (give business address if currently in business)
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
I request business consulting 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.
*
Yes
No
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 furnsih relevant information to the assigned management consultant(s). I further understand that the consultant(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 consultant(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. Please note: The estimated burden for completing this form is 18 minutes. Comments on the burden should be sent to: U.S. Small Business Administration, 409 3rd Street, SW, Washington, DC 20416, and to : Desk Officer SBA, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C., 20503. Please enter your full name, indicating your acceptance of the above terms.
*
Client Rights and Responsiblities
Please read the following and place a checkmark in the box to signify that you have read and agree to the Clients Rights and Responsibilities.
*
1. You are entitled to be treated with courtesy and consideration by your consultant and other UMWSBDC personnel.
*
2. You are entitled to professional consulting services and be advised if the UMWSBDC is unable to provide services within the time frame required.
*
3. You have the right to privacy regarding information shared with the UMWSBDC. No information provided by you will be used to the commercial or other advantage of any staff member, consultant, or other resource of the UMWSBDC or to the advantage of any third party.
*
4. You are entitled to confidentiality of your client status with UMWSBDC. No public use of your name, address or business identity will be made without your expressed written prior approval. UMWSBDC is required to provide limited information with respect to your client status to the U.S. Small Business Administration.
*
5. You will receive email notifications from UMW SBDC but you will have the option to unsubscribe anytime you want to. ( By signing this form, you are agreeing to receive emails from UMW SBDC email platform).
*
6. You are entitled to be charged a reasonable fee for training programs, special services, and publications. However you have the right to feel secure that no fee will be charged by UMWSBDC for the normal consulting services provided to you.
*
7. You may not be refused services on the basis of race, creed, color, religion, sex, age, national origin or disability.
*
8. Your acceptance of management and technical assistance from UMWSBDC means that you agree to waive all claims against UMWSBDC and its staff or any other resources employed by or used in connection with these services.
*
9. You are expected to cooperate with the UMWSBDC in its efforts to assure the quality and effectiveness of the consulting services it provides.
*
10. You are required to complete a brief impact assessment at the end of each calendar year in order to continue services.
Please enter your full name and today's date on the line below to signify that you have read and agree to the Clients Rights and Responsiblities as listed above.
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