Tel: 508-696-9687 Non-Profit Org. Request for Face-to ...
Tel: 508-696-9687 Non-Profit Org. Request for Face-to-Fact Counseling – Part I and Part II Bring this Completed Form to Initial Counseling Session
Type of Counseling: ( Circle one) Face-to- Face counseling Telephone Counseling Other Name of Non-Profit Organization: Mail Address: Email Address: Last Name:
First Name:
Middle Initial:
Email Address: Primary Phone:
Secondary phone:
Street Address:
City
State:
Zip Code:
Fax:
I request non-profit organization counseling services from the Small business Administration (SBA) or an SBA Resource Partner. I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA services. I permit SBA or its agent the use of my name and address for SBA surveys and information mailings regarding SBA products and services (circle Yes or 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 SBA to furnish relevant information to the assigned management counselor(s). I further understand that the counselor(s) agree 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 and host organizations, arising from this assistance.
Please describe your Non-profit organization and the specific assistance requested.
Within the Non-Profit structure, what is your position/title: What prompted you to contact us? Conference *Other client Workshop * Word of Mouth Media attention * Board member
* Volunteer Referral * Other:
Month & Year Non-Profit Started? If the Non-Profit has an endowment fund when was it created and what is the current amount: Total No. of Employees: Full time:
Part-Time:
Total No. of Board Members: Total Number of Volunteers: For your most recent year of operation, what were your:
gross income : income from donations: income from grants:
Type of Counseling: ( Circle one) Face-to- Face counseling Telephone Counseling Other Name of Non-Profit Organization: Mail Address: Email Address: Last Name:
First Name:
Middle Initial:
Email Address: Primary Phone:
Secondary phone:
Street Address:
City
State:
Zip Code:
Fax:
I request non-profit organization counseling services from the Small business Administration (SBA) or an SBA Resource Partner. I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA services. I permit SBA or its agent the use of my name and address for SBA surveys and information mailings regarding SBA products and services (circle Yes or 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 SBA to furnish relevant information to the assigned management counselor(s). I further understand that the counselor(s) agree 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 and host organizations, arising from this assistance.
Please describe your Non-profit organization and the specific assistance requested.
Within the Non-Profit structure, what is your position/title: What prompted you to contact us? Conference *Other client Workshop * Word of Mouth Media attention * Board member
* Volunteer Referral * Other:
Month & Year Non-Profit Started? If the Non-Profit has an endowment fund when was it created and what is the current amount: Total No. of Employees: Full time:
Part-Time:
Total No. of Board Members: Total Number of Volunteers: For your most recent year of operation, what were your:
gross income : income from donations: income from grants:
