Request for Consulting

The University of Scranton SBDC

Request for Consulting Services
University of Scranton Small Business Development Center

Note: This form is sent through an automatic email to our administrative staff. We will then place your information into a database used solely by the Pennsylvania Small Business Development Centers. You should receive a response to this form within 5 days.

The University of Scranton Small Business Development Center services businesses that has or will have headquarters within the following eight counties in Pennsylvania: Lackawanna, Bradford, Monroe, Pike, Susquehanna, Tioga, Wayne and Wyoming.

If your business is located outside these areas, please visit http://www.pasbdc.org/where/default.asp

Binghamton, NY area, Broome, Chenango, Cortland, Delaware, Otsego, Tioga and Tompkins counties in the Southern Tier of New York State, please contact the Binghamton University Small Business Development Center, located on Water St. in Binghamton. http://sbdc.binghamton.edu

For those of you wishing to do business in Skylands region of northwestern New Jersey, you need to contact the Warren County Community College SBDC by clicking here. This SBDC is located off of Rt. 57 in Washington, NJ.

If your business will operate in our 8-county service area in Pennsylvania, please continue with filling out our form.

You may also download a copy of our paper version of the form (in Adobe Acrobat format) to fax or mail to us by clicking here. Please complete and sign both pages of the printed form should you choose to complete the printed form rather than the online version below.

* = Required Field

Please provide the following information:

Company Name
(or what you anticipate it to be) ^*

Contact Name
(First & Last) ^*

Your Title (Mr., Ms., Mrs., Dr., Miss, etc)

Street Address

Address Line 2

City

County ^*

State/Province

Zip Code + 4 ^*-
(click here to look up your Zip+4)

Work Phone

Home Phone

FAX

E-mail

Web Address

What is (or will be) your position?
(Choose one): ^*

Are you (or will you be) the owner of the business? (Choose one):

Who is your State Representative?
(if known)
(look it up at www.congress.org)

Who is your State Senator?
(if known)

What is your Congressional District?
(if known)

What is (or do you anticipate) your business size?
(choose one) ^*

What date was (or do you expect) your business established? ^*mm/dd/yy

What is (or do you anticipate to be) your business type?
(select all that apply) Manufacturer

Service

Retail

Wholesale

Research and Development

Construction

Surplus Dealer

Not in Business

Are you (or do you expect to be) a home-based business?

What is (or will be) your organization type?
(choose one) ^*

# of full-time employees
Sole Proprietors, do not consider your self an employee

# of part-time employees

The United States Small Business Administration requests the following 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) ^*

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, or do you anticipate to be? Yes No

What is your SBA relationship?
(choose one)

By whom were you referred to the SBDC?
(choose one)

Describe the product or service you do/will offer:

^{*You must describe the product or service that you intend to sell.
This allows our Center Director to properly assign you to the business
consultant that can best serve you based on their levels of expertise
in certain areas or professional specialty.}

Are you a franchise? Yes   No

How can the SBDC assist you?
(select all that apply) Start-up/Acquisition

Locating sources of financing

Marketing/Sales

Government Procurement

Accounting

Financial Analysis/Cost Control

Inventory Control/Purchasing

Engineering

Personnel Management

Computer Systems/Web Site

International Trade

Sale of Business/Liquidation

Business Plan

Product Development

PLEASE READ THIS STATEMENT, THEN SIGN AND DATE THIS FORM

SBDC Client Rights and Responsibilities

You have the right to expect:

1. Consulting Assistance Provided at No Charge - Because the SBDC program is supported by funding from the US Small Business Administration, the Pennsylvania Department of Community and Economic Development, the University of Scranton 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:

Information about the SBDC's service delivery is reported in aggregate to its funding sources 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 funding sources 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 knowingly 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. 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 all claims of damages against the University of Scranton SBDC and the Pennsylvania SBDC program, the University of Scranton, the US Small Business Administration, and the Pennsylvania Department of Community and Economic Development, based on any advice or information provided by the SBDC.

I have read and understand the above stated terms and conditions.

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) ^*

The University of Scranton SBDC is partially funded under Cooperative Agreement No. 3-603001-Z-0040-23 by the U.S. Small Business Administration. The support given by the U.S. Small Business Administration through such funding does not constitute an express or implied endorsement or any of the co-sponsors' or participants' opinions, findings, conclusions, recommendations, products, or services. The University of Scranton is an affirmative action equal opportunity employer.