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Request for Service Form

Please fill out the form below so we may be able to help you with your business. A paper copy of this form may be downloded by clicking here. You must have Adobe Reader/Professional to view this file. A version of this program may be downloaded by clicking here.

Note: This form is sent through an email. We will then place your information into a database used solely by the Pennsylvania Small Business Development Centers.

The Lehigh University Small Business Development Center services the following four counties: Northampton, Lehigh, Upper Bucks, and Upper Montgomery. If you are outside these areas, please contact our office and we will direct you to the center who services your county.

Please provide the following information:
* Denotes required field

Company Name:	*
Title:	(Mrs., Ms., Mrs., Dr., Miss, etc.)
First Name:	*
Last Name:	*
Street Address
Address 2:
City:
County:	*
State/Province:
Zip Code + 4:	*-
Work Phone:		Ext:
	May we leave a detailed message at your work number? Yes No
Home Phone:
	May we leave a detailed message at your phone number? Yes No
Fax:
E-mail:
URL:

What is your position? (Choose one)
Are you the owner of the business? (Choose one)
Who is your Representative? (if known)
Who is your Senator? (if known)
What is your Congressional District? (if known)
What is your business size? (choose one)
What is your approximate annual sales? (enter $0 if no sales)
What date was (or will) your business established? (mm/dd/yyyy)
What is your business type? (select all that apply) Manufacturer Service Retail Wholesale Research and Development Construction Surplus Dealer Not in Business
Are you a home-based business?
What is your organization type? (choose one)
Number of full-time employees
Number of part-time employees

SBA Information

What is your race? (Choose one)	*
What is your ethnicity? Hispanic Origin Not of Hispanic Origin
Business owner gender: Male Female Male/Female Partnership
What is your military veteran status? (choose one)	*
Do you consider yourself a person with a disability? Yes No
Within the last two years, have you ever received: a. Aid to Families with Dependent Children (AFDC)? Yes No b. Temporary Assistance to Needy Families (TANF)? Yes No
Are you involved in International Trade? Yes No
What is your SBA Relationship? (Choose one)
Who were you referred by? (Choose one)
If you were referred to by a legislator, what what his/her name?
Describe the product/service you will/do offer: *
Are you a franchise? Yes No
How can the SBDC assist you? (Select all that apply) Start-up/Acquisition Sources of Financing Marketing/Sales Government Procurement Accounting Financial Analysis/Cost Control Inventory Control/Purchasing Engineering Personnel Management Computer Systems International Trade Business Sales/Liquidation Loan Applications Business Plan Product Development
Based on the areas for assistance that you selected above, briefly describe the nature of the counseling you are seeking:
Would you like to be contacted to participate in business-related academic research projects conducted by the Small Business Development Center and/or Lehigh University? Yes No

SBDC CLIENT RIGHTS AND RESPONSIBILITIES

As an SBDC client you have the right to expect:

1. Consulting Assistance Provided at No Charge - Because the SBDC program is supported by funding from the U.S. Small Business Administration, the Pennsylvania Department of Community Economic Development, the University and other funders, consulting is provided at no charge to you. Fees may apply for training programs, special services (such as research), materials, and publications.

2. Confidentiality of Information Provided - All SBDC representatives agree to abide by the Pennsylvania SBDC's Standards of Professional Ethics and Conflict of Interest Policy. Information you provide will be held in strictest confidence and will not be released to any parties outside of the Pennsylvania SBDC network. Information on you will not be sold or provided to other organizations. Specific information on you and the nature of your engagement with the SBDC will not be released without your consent. No information you provide will be used to the commercial advantage of any SBDC representative or to the advantage of a third party. Exceptions:

I nformation about the SBDC's service delivery is reported in aggregate to its funders and the general public. Specific information about you will not be released without your consent.

The SBDC will collect and report in aggregate to its funders and the general public information on you such as demographic statistics; size, location, age and industry of your business; the general nature of your engagement with the SBDC; and impact statistics such as financing obtained, sales increased or jobs created.

If you were referred to the SBDC, the SBDC will notify the referrer that you have sought assistance from the SBDC. The SBDC, however, will not disclose in detail the nature of the assistance you are requesting.

3. Unbiased Recommendations - SBDC representatives will not recommend the purchase of goods or services from any individual or firm with which any SBDC representative has a financial, familial or personal interest.

4. Non-Disclosure of Trade Secrets - Sensitive trade secrets pertaining to unique facts of your business will not be used to benefit another client of the SBDC or any SBDC representative. You understand that sensitive trade secret information is information, which is not obvious, which is unknown, or which is unique and pertains to new inventions, secret manufacturing and processing procedures or formulas, or any new innovative process. You understand that it is your responsibility to inform the SBDC of any such sensitive trade secrets both verbally and in writing.

5. Assistance, Guidance, Recommendations and Education - The SBDC program is an educational program. The SBDC will work with you on your specific issues to help build your management skills and knowledge. It is your responsibility to accept and implement recommendations. The SBDC will not:
-negotiate on your behalf
-write your business plan
-act as an employee of your business

As an SBDC client you are responsible for:

1. Participating in Surveys - Because this program cares about the quality of services provided, and because it is primarily funded with public support, the SBDC undertakes a number of initiatives to ascertain the quality and impact of services provided to you. Your candid feedback is critical to the long-term success of this program.

2. Informing Legislators About the Service - Consulting services are provided at no charge to you because of the financial support of the federal government and the Commonwealth of Pennsylvania. To ensure the SBDC program will be available to others, we may ask you to write to your legislators to let them know about your experience with the program.

3. Accepting Responsibility and Waiving all Claims - In recognition that you are ultimately responsible for the success or failure of your business and that all decisions pertaining to implementing plans and operating your business are solely your responsibility, you hereby waive any claims of damages against the Lehigh University SBDC, the trustees of Lehigh University and the Pennsylvania SBDC program, the Lehigh University, the US Small Business Administration, and the Pennsylvania Department of Community and Economic Development, based on any advice or information provided by the SBDC.

PLEASE READ THIS STATEMENT, THEN SIGN AND DATE THIS FORM

I request management assistance from the Small Business Administration and/or the Lehigh University Small Business Development Center. I understand this assistance is free of charge. I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA/SBDC assistance services. I authorize the SBA/SBDC to furnish information to the assigned management consultant(s). I understand that any information disclosed is to be held in strict confidence by him/her.

I further understand that any consultant has agreed: (1) not to recommend goods or services from sources in which he/she has an interest, and (2) will not accept fees or commissions developing from this consulting relationship.

In consideration of SBA/SBDC furnishing management or technical assistance, I waive all claims against SBA/SBDC personnel and its host organizations arising from this assistance.

Electronic Signature: (enter your name) *

Date: *mm/dd/yy

By means of an electronic signature I understand I am agreeing to the terms listed above.
Initials: (enter your initials) *

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Request for Service Form

Please provide the following information:

Company Name:

*

Title:

(Mrs., Ms., Mrs., Dr., Miss, etc.)

First Name:

*

Last Name:

*

Street Address

Address 2:

City:

County:

Bucks Lehigh Montgomery Northampton Other *

State/Province:

Zip Code + 4:

*-

Work Phone:

Ext:

May we leave a detailed message at your work number?

Yes No

Home Phone:

May we leave a detailed message at your phone number?

Yes No

Fax:

E-mail:

URL:

What is your position? (Choose one)

Are you the owner of the business? (Choose one)

Who is your Representative? (if known)

Who is your Senator? (if known)

What is your Congressional District? (if known)

What is your business size? (choose one)

What is your approximate annual sales? (enter $0 if no sales)

What date was (or will) your business established? (mm/dd/yyyy)

What is your business type? (select all that apply)

Are you a home-based business?

Yes No

What is your organization type? (choose one)

Individual (Sole Proprietor) Partnership Non-Profit Organization Corporation Sub S Corporation Limited Liability Company

Number of full-time employees

Number of part-time employees

SBA Information

What is your race? (Choose one)

What is your ethnicity?

Business owner gender:

What is your military veteran status? (choose one)

Do you consider yourself a person with a disability?

Within the last two years, have you ever received:

a. Aid to Families with Dependent Children (AFDC)?

b. Temporary Assistance to Needy Families (TANF)?

Are you involved in International Trade?

What is your SBA Relationship? (Choose one)

Who were you referred by? (Choose one)

If you were referred to by a legislator, what what his/her name?

Describe the product/service you will/do offer: *

Are you a franchise?

How can the SBDC assist you? (Select all that apply)

Based on the areas for assistance that you selected above, briefly describe the nature of the counseling you are seeking:

Would you like to be contacted to participate in business-related academic research projects conducted by the Small Business Development Center and/or Lehigh University?

SBDC CLIENT RIGHTS AND RESPONSIBILITIES

As an SBDC client you have the right to expect:

As an SBDC client you are responsible for:

PLEASE READ THIS STATEMENT, THEN SIGN AND DATE THIS FORM

*