I request business training and/or counseling service from the Small Business Administration (SBA) or an SBA Resource Partner. I am a U.S citizen, a Permanent U.S. resident, or a citizen of the Freely Associated States. SBDC services are not available to individuals or entities that have been debarred or suspended by the federal government.  By agreeing to receive assistance from the SBDC, I self-certify that neither I nor my company have been suspended or debarred by a federal agency and also agree to cease using SBDC services if I or my company become federally debarred or suspended in the future. Should I start a business, I agree to provide the SBDC with a signed Verification of Economic Impact Form and a copy of my business license, contractor’s license, certified farmer certification, or any other license relevant to my business. I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA services. I permit SBA or its agent the use of my name and address for SBA surveys and information mailings regarding SBA products and services. I understand that any information disclosed will be held in strict confidence. (SBA and the SBDC will not provide your personal information to commercial entities). 

I authorize the SBDC to furnish relevant information to the assigned SBDC advisor(s). I further understand that the advisor 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 advisor furnishing management or technical assistance, I waive all claims against SBDC personnel and that of its Resource Partners and host organizations arising from this assistance. 

Please note: The estimated burden for completing this form is 1 minutes. 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, 409 3rd Street, SW, Washington, DC 20416, and to: Desk Officer SBA, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C., 20503. OMB Approval (3245-0324). PLEASE DO NOT SEND FORMS TO OMB.

I understand that there are no warranties or assurances in connection with the counseling assistance.