Northern California SBDC Network
 


Sign Up for Services


Thank you for your interest in our program's services. Please select a center nearest to your location and a representative will contact you shortly upon completion of this form.
Please select your nearest center
All mandatory fields appear in bold.
First:
MI: Last:
Street Address:
City: State:
Zip Code:
 
Home Phone: Work Phone:
E-mail: Fax Number:
Yes, I would like to be included in future center mailings.
Please complete the following fields so that we may better serve you in the future. All information provided here will remain confidential.
Gender: Race:
Hispanic: Veteran:
Reservist: Disabled:
Company Status: Business Type:
Briefly describe your current or proposed company's products/services:

Please complete the following details about your company.
Company Name: Date Established:
Organization Type:
Company Gender: Company Veteran Status:
Full-Time Employees: Part-Time Employees:
Business Online? Home-based Business?
Company Web Site:
Referral From: Assistance Requested:      
Please describe specific assistance requested:
INFORMATION NOTICE

The information requested on this Request for Counseling Form (SBA Form 641) will assist the Northern California SBDC Network in serving you and responding to sponsors' requests for information about SBDC performance. As a matter of law, SBDCs may not disclose the name, address, or telephone number of any individual or small business concern receiving assistance without the consent of such individual, unless specifically instructed to do so under court order or required by law. Except for signing this form you are not required to provide any of the requested information as a condition of receiving service. Other non-personal information you provide may be considered public.

By accepting these terms you agree, if selected, to participate in surveys designed to evaluate the services and impact of the Northern California SBDC Network. Any information disclosed in such surveys will be held in strict confidence.

By accepting these terms you further understand that Northern California SBDC counselors are prohibited from:
1) recommending goods or services from sources in which the counselor has a financial interest.
2) accepting fees or commissions developing from the counseling relationship.

In consideration of the counselor furnishing management or technical assistance, you waive all claims against the U.S. Small Business Administration, the Northern California Small Business Development Center Network, and that of its resource partners, any of its independent contractors and host organizations, and their personnel, arising from the assistance.

The estimated burden for completing this form is 3 minutes per response. You are not required to respond to any collection information unless it displays a currently valid OMB approval number. Comments on the burden should be sent to U.S. Small Business Administration, Chief, AIB 409 3rd St., S.W., Washington, D.C. 20416 and Desk Officer for the Small Business Administration, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503. OM B approval (3245-0091) Please do not send forms to OMB
Please provide your full name (First, Middle, Last) indicating your acceptance to the terms shown above.
Date: