Contact Information


Company name:

Owner's name (first, last):

Contact name (first, last):

Title for contact person (Mr., Mrs., Ms.):

Address line 1:

Address line 2:

City:

County:

State:

Zip code:

Work phone:

Home phone:

FAX:

E-Mail (required):

Website:

What is your position?

Are you the owner of the business?

What is your business size?

What is your business type?

Are you a home based business?

What is your organization type?

What date was (or will) your business established?

# of full-time employees

# of part-time employees


What is your race?

What is your ethnicity?

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)
b. Temporary Assistance to Needy Families (TANF)

Are you involved in international trade?

What is your SBA relationship?

How did you learn about the SBDC/Who referred you?

Describe the product or service you do/will offer:

Are you a franchise?

Request for Services

Terms and Conditions

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.

Client Rights and Responsibilities

As an SBDC client you have the right to expect:

  1. Consulting Assistance Provided at No Charge – Because the SBDC program is supported by funding from the U.S. Small Business Administration, the Pennsylvania Department of Community Economic Development, Bucknell University and other funders, consulting is provided at no charge to you. Fees may apply for training programs, special services (such as research), materials, and publications.
  2. Confidentiality of Information Provided – All SBDC representatives agree to abide by the Pennsylvania SBDC’s Standards of Professional Ethics and Conflict of Interest Policy. Information you provide will be held in strictest confidence and will not be released to any parties outside of the Pennsylvania SBDC network. Information on you will not be sold or provided to other organizations. Specific information on you and the nature of your engagement with the SBDC will not be released without your consent. No information you provide will be used to the commercial advantage of any SBDC representative or to the advantage of a third party.

Exceptions:

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:

  1. Unbiased Recommendations - SBDC representatives will not knowingly recommend the purchase of goods or services from any individual or firm with which any SBDC representative has a financial, familial or personal interest.
  2. Non-Disclosure of Trade Secrets – Sensitive trade secrets pertaining to unique facts of your business will not be used to benefit another client of the SBDC or any SBDC representative. You understand that sensitive trade secret information is information which is not obvious, which is unknown, or which is unique and pertains to new inventions, secret manufacturing and processing procedures or formulas, or any new innovative process. You understand that it is your responsibility to inform the SBDC of any such sensitive trade secrets both verbally and in writing.
  3. Assistance, Guidance, Recommendations and Education – The SBDC program is an educational program. The SBDC will work with you on your specific issues to help build your management skills and knowledge. It is your responsibility to accept and implement recommendations. The SBDC will:
  • not negotiate on your behalf
  • not write your business plan
  • not act as an employee of your business

As an SBDC client you are responsible for:

  1. Participating in Surveys – Because this program cares about the quality of services provided, and because it is primarily funded with public support, the SBDC undertakes a number of initiatives to ascertain the quality and impact of services provided to you. Your candid feedback is critical to the long-term success of this program.
  2. Informing Legislators About the Service – Consulting services are provided at no charge to you because of the financial support of the federal government and the Commonwealth of Pennsylvania. To ensure the SBDC program will be available to others, we may ask you to write to your legislators to let them know about your experience with the program.
  3. Accepting Responsibility and Waiving all Claims – In recognition that you are ultimately responsible for the success or failure of your business and that all decisions pertaining to implementing plans and operating your business are solely your responsibility, you hereby waive any claims of damages against the Bucknell University SBDC and the Pennsylvania SBDC program, Bucknell University, the US Small Business Administration, and the Pennsylvania Department of Community and Economic Development, based on any advice or information provided by the SBDC.

Acceptance of Terms and Conditions and Acknowledgment of Rights and Responsibilities

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)

Date:

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