Date:

Type of Action(Select One): One Time: Initial:   Information:

First Name: Last Name:

Company Name: Title:

Mailing Address:

City: State: Zip:

County:

Phone(Business): Phone(Cel):

Phone(Home): Fax:

Best Time to Contact: Morning  Afternoon

Email:

I request business management counseling from the Small Business Development Center. I agree to cooperate should I be selected to participate in surveys designed to evaluate SBDC assistance services. I authorize SBDC to furnish relevant information to the assigned management counselor(s) although I expect that information to be held in strict confidence by him/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 SBDC's furnishing management or technical assistance, I waive all claims against SBDC personnel, SCORE, SBA and it's host organizations, SBI, and other SBDC Resource Counselors, arising from this assistance.

SBA Form 641 (Ohio Version 02-10-2000)

r