Request for Consulting Form
SBDTC Form 641 Revised 3/16/2016
(Name of person completing this form/representative of the business)
(First Last)
Position/Title (if already in business)
(if already in business)
Street Address/PO Box (give business address if currently in business)
Business Description/Type
DEMOGRAPHIC INFORMATION
Asian
Black or African American
Native American or Alaska Native
Native Hawaiian or other Pacific Islander
White
Hispanic
Origin
Not of
Hispanic
Origin
Male
Female
Non-Veteran Veteran Service-Disabled Veteran
yourself a person
with a disability?
Yes No
Member of Reserve or National Guard
On Active Duty
BUSINESS DATA
Are you currently in business?
Yes
No (if no, skip to next section)
business start?
Mo.:_____ Yr.:________
What is the legal entity of your business?
Sole Proprietorship Corporation LLC
S-Corporation Partnership
Other (specify) ________________________
currently export?
Yes No
business?
Yes No
business online?
Yes No
business is female
owned? _________%
Full Time:__________
Part Time:__________
For your most recent full business year:
G
ross Revenues / Sales $_______________
ASSISTANCE REQUESTED
Describe specific assistance requested:
How did you hear about the ASBTDC? (SBA, bank, former client, Internet, etc.)
I request business consulting service from the Arkansas Small Business and Technology Development Center (ASBTDC). I agree to participate in surveys conducted by ASBTDC or SBA
designed to evaluate ASBTDC services and economic impact. I Agree
I permit ASBTDC or its agent the use of my name and address to survey me regarding ASBTDC services that I will receive. (Yes No )
I understand and agree that my consultant may have communications on my behalf with bankers, accountants, and other professional service providers. (Yes No )
I
understand that any information disclosed will be held in strict confidence. I authorize ASBTDC to furnish relevant information to the assigned management consultant(s). ASBTDC may
provide unidentifiable, aggregate company data to affiliated university researchers. I further understand that the consultant(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 consulting relationship. In consideration of the consultant(s) furnishing management or technical
assistance, I waive all claims against SBA personnel, and that of ASBTDC and host organizations, arising from this assistance. I certify that neither my firm nor I are currently suspended or
debarred by a federal agency.
Client Signature___________________________________________________ Date:____________________
click to sign
signature
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