I request business counseling service from a Small Business Administration (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 (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 SBA to furnish relevant information to the assigned management counselor(s). I further understand that any counselor has agreed 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 of its Resource Partners and host organizations, arising from this assistance. Please note: The estimated burden for completing this form is 3 minutes per response. You are not required to respond any collection information unless it displays a currently valid OMB approval number. All SBA funded programs are extended to the public on a nondiscriminatory basis.

Comments on the burden should be sent to U.S. Small Business Administration, 409 3rd St., S.W., 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 (3245-0091). PLEASE DO NOT SEND FORMS TO OMB.