Request for Services

Thank you for your interest in our program's services. Please fill out this short forma and a representative will contact you shortly.

All mandatory fields appear in bold.

First:

MI:

Last:

Street Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

E-mail:

Fax Number:

Yes, I would like to be included in future center 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 Type:
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 management assistance from the Business Assistance Center (BAC). I agree to cooperate should I be selected to participate in surveys designed to evaluate BAC assistance services. I authorize BAC to furnish relevant information to the assigned management counselor(s), although I expect that information to be held in strict confidence. I futher understand that all counselors have agreed not to recommend goods or services from sources in which he/she has an interest. BAC will NOT accept fees or commissions developing from this counseling relationship. In consideration of furnishing management or technical assistance, I waive all claims against SCORE, State of California, BAC and its host organizations, SBI, and any other resource counselors arising from this assistance.
Please provide your full name (First, Middle, Last) indicating your acceptance to the terms shown above.
Name: Date: