REQUEST FOR CONSULTING SERVICES
Clarion University Small Business Development Center

To view a printable version of our Request for Consulting form, Click Here. You can then fill it out and send it to our office. Please send forms to:

                      Attention: Request For Counseling
                      Clarion University Small Business Development Center
                      102 Dana Still Hall
                      Clarion University
                      Clarion PA 16214

Note: The form below is sent through an email. We will then place your information in a database used solely by the Pennsylvania Small Business Development Centers. You should receive a response to this form within 5 days.

The Clarion University Small Business Development Center services the following ten counties: Armstrong, Cameron, Clarion, Clearfield, Elk, Forest, Jefferson, McKean, Potter, and Venango. If you are outside these areas, please contact our office and we will direct you to the center who services your county. Click Here> All Other Pennsylvania SBDC's

*Required Field

Please provide the following contact information:

Company Name	*^{^}**
Contact Name (first, last)	*^{^}**
Title
Street Address
Address 2
City
County
State/Province
Zip Code + 4	^*
Work Phone	Ex. (814) 455-0909
Home Phone	Ex. (814) 455-0909
FAX	Ex. (814) 455-0909
E-mail
URL

What is your position? (Choose one):	^*
Are you the owner of the business? (Choose one):	Yes No
Who is your State Representative? (if known)
Who is your State Senator? (if known)
What is your Congressional District? (if known)
What is your business size? (choose one)	^*
What date was (or will) your business established?	^*(mm/dd/yyyy)
What is your major business type? (select one)
Service	Retail
Research	Wholesale
Construction	Surplus
Manufacturer	Not in Business

Are you a home-based business?	Yes No

What is your organization type? (choose one)

# of full-time employees

# of part-time employees

SBA Information:

What is your race: (choose one)

What is your ethnicity?

Business Owner Gender:

What is your military veteran status? (choose one)

Within the last two years, have you ever received:
a. Aid to Families with Dependent Children (AFDC) Yes No

b. Temporary Assistance to Needy Families (TANF) Yes No

Are you involved in International Trade? Yes No

What is your SBA Relationship?

Who were you referred by? (Choose One)

Describe the product or service you do/will offer:

Are you a franchise? Yes No

How may the SBDC assist you? (Select all that apply)

	Startup
	Financing
	Marketing
	Government Procurement
	Accounting
	Financial Analysis
	Inventory
	Engineering
	Personnel Management
	Computer Systems
	International Trade
	Business Sales
	Loan Application
	Business Plan
	Product Development

PLEASE READ THIS STATEMENT, THEN SIGN AND DATE THIS FORM

I request management assistance from the Small Business Administration and/or the Clarion 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.

Electronic Signature: (enter your name) *

By means of an electronic signature I understand I am agreeing to the terms listed above.
Initials: (enter your initials) *

Funding support and resources are provided by the Commonwealth of Pennsylvania through the Department of Community and Economic Development; through a cooperative agreement with the US Small Business Administration, and through support from Clarion University. All services are extended to the public on a non-discriminatory basis. Special arrangements for persons with disabilities can be made by calling Kris Stiglitz at (814) 393-2060. All opinions, conclusions or recommendations expressed are those of the author(s) and do not necessarily reflect the views of the SBA.