OUR CHAPTER

ARIZONA SCORE

NATIONAL SCORE


Counseling Request Form

Name ( First Last ) Street
City
State Zip E-Mail
Primary Phone
xxx-xxx-xxxx 		Secondary Phone
xxx-xxx-xxxx 		Fax
xxx-xxx-xxxx
Business Ownership
 Male        Female		 Total No. of Employees
(full & part-time)  		What is the legal entity of your business?
For your most recent full business year, what were your:
Gross Revenues/Sales $ 

Profits/Losses $ 
Race:
 Currently in business? Yes

 

 No
Ethnicity:
 Home Based? Yes

 

 No
Gender:
 Online business? Yes

 

 No
Disabled?
 Type of Business
Veteran Status:
Name of Company
Nature of  counseling Month & Year started:
(01)
(2006)
Preferred date of appointment
(mo/date/year)		 Referred By

 
I request business counseling service from the Small Business Administration (SBA) or SBA Resource Partner. I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA services. I understand that any information disclosed to be held in strict confidence. ( SBA will not provide your personal information to commercial entities. ) I authorize SBA to furnish relevant information to the assigned management counselor(s). I further understand that the counselor(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 counselor(s) furnishing management or technical assistance, I waive all claims against SBA personnel, and that of their Resource Partners and host organizations, arising from this assistance.
To request counseling

Thank you.
Please call our office with any questions, 928-778-7438.

Comments:

NOTE: You will be required to sign and date this form when you appear for counseling.

   
   

Northern Arizona SCORE: 1228 Willow Creek Road, Suite 2 - Prescott, AZ 86301 MAP
Phone: (928) 778-7438 - Toll Free: (800) 410-2260 Fax: (928) 778-4129 - E-Mail: score@northlink.com

An RLS Web Design Solution