Please note: The information gathered from this form is used only by Small Business Development Center staff and is NOT made public.

Contact information: (Items with * are required)

First Name:*
Last Name: *
Business Name: *

Address:*
 
City:*
State/Province:*   Zip:  
Country
Website Address:
Email Address:*

Phone Numbers:
   
Home:  
Business:  
Cellular:

Business Information:
   
Currently in Business?*  
Is this a Home-based Business?*  
Name of Business:
Describe your business:
  
Request for counseling information*
Describe the nature of the counseling you are seeking


Best time for contact:
Best Contact Method:


Would you like to tell us more about yourself and/or your business? 
Fill out the optional fields below to better prepare your advisor for your meeting. 


New York State Small Business Development Center Client Disclaimer (Required)

I request management assistance from The New York State Small Business Development Center. I understand that this assistance is free of charge and that I incur no obligation to The New York SBDC or the U.S. Small Business Administration or its counselors for providing this assistance. I agree to cooperate should I be selected to participate in surveys designed to evaluate assistance services. I authorize the New York SBDC to furnish relevant information to the assigned management counselor(s) although I expect that information to be held in strict confidence to the extent allowable by law.

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 the SBDC, in cooperation with the SBA furnishing management or technical assistance, I waive all claims against The New York SBDC, SBA, personnel or counselors arising from this assistance.




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