Owner's name (first, last):
Contact name (first, last):
Title for contact person (Mr., Mrs., Ms.):
Address line 1:
Address line 2:
What is your position?
Are you the owner of the business?
What is your business size?
Disadvantaged SBA (8a) Small
What is your business type?
Research and Development
Not in Business
Are you a home based business?
What is your organization type?
Individual (Sole Proprietor)
Sub S Corporation
Limited Liability Company
What date was (or will) your business established? # of full-time employees # of part-time employees
What is your race?
Native American or Alaskan Native
Black or African American
Native Hawaiian or other Pacific Islander
What is your ethnicity?
Not of Hispanic Origin
Business owner gender
What is your military veteran status?
Within the last two years, have you ever received: a. Aid to Families with Dependent Children (AFDC) Yes No b. Temporary Assistance to Needy Families (TANF) Yes No
Are you involved in international trade? Yes No
What is your SBA relationship?
Not an SBA client
8(a) Security Bond
How did you learn about the SBDC/Who referred you?
Chamber of Commerce
Print Media (newspaper/magazine)
Word of Mouth
Describe the product or service you do/will offer:
Are you a franchise? Yes No
How can the SBDC assist you? (select all that apply)
Start-up/Acquisition Sources of Financing Marketing/Sales Government Procurement Accounting Financial Analysis/Cost Control Inventory Control/Purchasing Engineering Personnel Management Computer Systems International Trade Business Sales/Liquidation Loan Applications Business Plan Product Development Business Disruption
I request management assistance from the Small Business Administration and/or the Bucknell University Small Business Development Center. I understand this assistance is free of charge. I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA/SBDC assistance services. I authorize the SBA/SBDC to furnish information to the assigned management consultant(s). I understand that any information disclosed is to be held in strict confidence by him/her.
I further understand that any consultant has agreed: (1) not to recommend goods or services from sources in which he/she has an interest, and (2) will not accept fees or commissions developing from this consulting relationship.
In consideration of SBA/SBDC furnishing management or technical assistance, I waive all claims against SBA/SBDC personnel and its host organizations arising from this assistance.
As an SBDC client you have the right to expect:
Information about the SBDC’s service delivery is reported in aggregate to its funders and the general public. Specific information about you will not be released without your consent.
The SBDC will collect and report in aggregate to its funders and the general public information on you such as demographic statistics; size, location, age and industry of your business; the general nature of your engagement with the SBDC; and impact statistics such as financing obtained, sales increased or jobs created.
If you were referred to the SBDC, the SBDC will notify the referrer that you have sought assistance from the SBDC. The SBDC, however, will not disclose in detail the nature of the assistance you are requesting.
The Pennsylvania Small Business Development Centers maintain strict confidentiality relative to all matters relating to its clients. The only condition under which a Small Business Development Center (SBDC) can share client information with other organizations is if the client provides explicit written permission to do so. Because there are economic development and growth programs outside of the SBDC from which clients may benefit, and because engaging the services of these other programs in a collaborative and complementary fashion with SBDC services can provide enhanced benefit to our clients, if in the course of your consulting engagement, you and your consultant agree you can benefit from the services provided by our Pennsylvania Department of Community and Economic Development (DCED) funded Partnership for Regional Economic Performance (PREP) partners, the SBDC may release your name, contact information, company name, business type and type of assistance provided to the Pennsylvania DCED and designated member organizations in the PREP program.
› Please type YES that you agree or NO that you do not agree to these exceptions:
As an SBDC client you are responsible for:
By means of an electronic signature below and by checking this box I indicate that I have read, understand, and agree to the above stated terms and conditions and to the SBDC Client Rights and Responsibilities.
Electronic Signature (required): (enter your name)
Lewisburg, PA 17837
ph: 570.577.2000Mailing address details
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