FY2019
The information on this form is confidential and will be used only to report to the funding organizations, provide client
services, inform you about and improve the SBDC services. The estimated time to fill out the form is three minutes.
DATE
COMPANY NAME (leave blank if not in business)
ARE YOU THE BUSINESS OWNER?
Yes
No
FIRST NAME
M.I.
LAST NAME
EMAIL
PHONE
COMPANY OR HOME CELL
ADDRESS (if in business, provide company address)
STREET
ST
ZIP
COUNTY
GENDER
RACE
HISPANIC ORIGIN
Female
Alaska Native
Native Hawaiian/Pacific Islander
Hispanic
Male
Asian
White/Caucasian
Non-Hispanic
Choose
not to
respond
Black/African American
Choose not to respond
Choose not to
respond
Native American
VETERAN STATUS MILITARY STATUS DISABLED
Non-Veteran
Active Duty
None
No
Service-Disabled Veteran
Military Spouse
Reservist
Yes
Veteran
National Guard
Reservist – Active Duty
Choose
not to
respond
Choose not to respond
National Guard
Active Duty
Choose not to respond
If in business, turn over and complete Company Information.
7/28/2020
NAME OF TRAINING
Cyber Security for Small Businesses
FY2019
Company Information
(if currently in business)
The information on this form is confidential and will be used only to report to the funding organizations, provide client
services, inform you about and improve the SBDC services. The estimated time to fill out the form is three minutes.
Please fill out completely
BUSINESS TYPE (Manufacturing, Construction, Technology, Retail, etc.)
DATE COMPANY ESTABLISHED
OWNERSHIP GENDER
/ / % Male % Female
NUMBER OF FULL-TIME EMPLOYEES
NUMBER OF PART-TIME EMPLOYEES
GROSS REVENUE/SALES FOR MOST
RECENT BUSINESS YEAR
COMPANY LEGAL STATUS
(LLC, Sole Proprietor, S-Corp, etc.)
$
PRODUCTS OR SERVICES
I request training and/or business counseling service from the Ohio Small Business Development Centers (SBDC),
funded in part through a Cooperative Agreement with the U.S. Small Business Administration (SBA). I agree to
cooperate should I be selected to participate in surveys designed to evaluate these services, impact, and/or make
improvements on 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 (Yes 0 No 0). I understand that any information disclosed will 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 dev
eloping 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 its Resource
Partners and host organizations, arising from this assistance. Please note: The estimated burden for completing this
form is 3 minutes. 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.
SIGNATURE
DATE
Not Required
Not Required
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