Maine Small Business Development Centers
REQUEST FOR COUNSELING
NOTE: These services are for Maine residents or those considering doing business in Maine. If you are located in another state, you can find an SBDC in your area at Click Here
First Name:
Last Name:
Position:
 Business Phone: (207-555-5555)
 Office Use
Business Name:
Business Fax: (207-555-5555)
 Check to be excluded from SBDC Mailings
(does not apply to surveys)
Mailing Address
 Home Phone: (207-555-5555)
 County District
City
 State
 ZipCode
 Email
WebPage
 Disabled/Handicap
Business Status:
Currently in Business
Home Business
Online Business 		Business Start Date (format 12/31/2008)
 What percentage of your business is female owned? %

Number of Employees
Full Time
Part Time

Annual Sales:
Annual Profit/Loss: 		Gender:
Type of Business:
 NAICS Code(s) What is this?
 Veteran Status: Military Status:
Business Organization:
Race:
Asian
Black or African American
Native American
Native Hawaiian or Pacific/Islander
White
No Reply

Hispanic Origin
Business Description: (Briefly describe your business.)
Indicate Preferred date and time for appointment:
 Indicate, briefly, the nature of the service and/or counseling you are seeking:
Please indicate which office would be the most convenient for you.
Client Release

I request business counseling service from the Maine Small Business Development Centers (SBA Resource Partners). I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA services.

I understand that any information disclosed will be held in strict confidence. (Maine SBDC, Women's Business Centers at Coastal Enterprises Inc. or 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 developing 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 (Maine SBDC and Women's Business Centers) and host organizations, arising from this assistance.

Please Print your full name
 I agree with the above statement and accept the terms by checking this box. Date
Please contact Chris Long at (207) 780-4949 if you have problems with this form.