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I request business management counseling from a Small Business Administration resource partner, the Small Business Development Center. I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA assistance services. I understand that any information received by an SBA resource partner counselor will be held in strict confidence by the counselor to the extent allowable by law. I further understand that SBA resource partner counselors have agreed not to: (1) recommend goods or services from sources in which the individual counselor has an interest; and (2) accept fees or commissions developing from any SBA resource partner counselors. In consideration of the provision of management and/or technical assistance by a resource partner counselor, I agree to waive all claims arising out of this assistance, against SBA personnel, the resource partner from whom I sought assistance, its host organizations, and the counselor(s) arising from this assistance.

I self-certify that I am not currently debarred, suspended or declared ineligible from doing business with any federal department or agency.

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 will not provide your personal information to commercial entities.)

Please provide your full name (First, Middle, Last) indicating your acceptance to the terms shown above.