eCenter Direct - Request For Services

Alaska SBDC, Great North: Sign-up For Services Thank you for your interest in our program's services. Please complete this form and a representative will contact you shortly.

All mandatory fields appear in bold.

First:

MI:

Last:

Street Address:

City:

State:

Zip Code:

County:

Home Phone:

Work Phone:

E-mail:

Fax Number:

Cell Phone:

Yes, I would like to be included in future center e-mailings.

Please complete the following fields so that we may better serve you in the future. All information provided here will remain confidential.

Gender:

Race:

Hispanic:

Veteran:

Reservist:

Disabled:

Company Status:

Business Type:

Briefly describe your current or proposed company's products/services:

Please complete the following details about your company.
Company Name:		Date Established:
Organization:
Company Gender:		Company Veteran Status:
Full-Time Employees:		Part-Time Employees:
Business Online?		Home-based Business?
Company Web Site:

Referral From:

Assistance Requested:

Please describe specific assistance requested:

I request business counseling assistance from the Small Business Administration (SBA) or an SBA Resource Partner, Alaska Small Business Development Center, (SBDC). I agree to cooperate should I be selected to participate in surveys designed to evaluate the SBA/SBDC services. I permit SBA or its agent, SBDC, the use of my name and address for SBA/SBDC surveys and information mailings regarding SBA/SBDC products and services (Yes __ No ___ ).

I understand that any information disclosed will be held in strict confidence. (SBA will not provide your personal information to commercial entities.) I authorize the SBA/SBDC 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, SBDC, and host organizations, arising from this assistance.

Pleae note: The estimated burden for completing this form is 3 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 Adminitration, 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.

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

Alaska SBDC, Great North: Sign-up For Services