However, filling out Form 641 does not guarantee that the Maricopa SBDC
will provide such counseling. A consultant for the Maricopa SBDC will make a decision
as to whether or not to engage in a consulting relationship based upon their available
time and their ability to be of assistance to you.

In order for them to make this decision, you may be asked for additional information.

c. Are you disabled? Yes No

d.  What is your legal structure?    

     (Sole, Partnership, Corp, LLC, etc.) 

Is this a woman owned business? Yes No 

NOTICE:
BY SUBMITTING THIS FORM, YOU ARE AGREEING TO THE FOLLOWING:

I request business management counseling service from a Small Business Administration Resource
Partner. I agree to cooperate should I be selected to participate in surveys designated to evaluate
SBA assistance services. I authorize SBA to furnish relevant information to the assigned management
counselor(s). I understand that any information disclosed will be held in strict confidence by him/her.

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 for the counselor(s) furnishing management or technical
assistance, I waive all claims against SBA personnel, SCORE and its host organizations, and other
SBA Resource Counselors arising from this assistance.Counselor/Client Understanding of Expectations
Financial Information Disclaimer

Congratulations on your choice to call upon the Arizona Small Business Development Center SBDC Network. We are committed to helping you build a better business.

SBDC program funding is evaluated according to economic impact produced. Periodically, you will be contacted to obtain updated information regarding your business’s economic impact (jobs, increase in sales etc.). You, as a client are expected to respond with accurate feedback.

You can expect:

 Guidance from experienced business counselors.
 Help in developing a clear path toward accomplishing your goals
 Objective and constructive feedback about your progress toward your goals
 Courteous treatment from all Small Business Development Center staff
 Complete confidentiality regarding every aspect of the information we discuss with you
 Prompt personal attention from Center management to resolve any problems or complaints about the service you receive
 Follow up contact from SBDC personnel regarding your business’s economic impact

We expect you to:

 Communicate honestly and directly about all aspects of your business
 Follow through on the work you and your business counselor agree is necessary to accomplish your goals
 Be open-minded about alternatives your business counselor suggests
 Provide a minimum of 24 hours notice if you are unable to keep any appointment with a business counselor
 Assist us in the future by providing frank feedback about the quality of service you received from us and about the progress of your business by responding to a survey from time to time
 Respond to requests for information from SBDC personnel regarding your business’s economic impact

Client Financial Information Disclaimer/Client Representation

In the event that the SBDC provides client with assistance in preparing financial plans, pro forma financial statement, or other types of reports or forecasts, it is understood that all source and input data and assumptions about such data will be provided by the owner/officers of the company not the SBDC. The SBDC will not be responsible for validating data.

Neither the SBDC nor its staff is permitted to represent, negotiate or advocate on behalf of the client or the client’s company under any circumstances.

Client reaffirms and agrees to the above by clicking on the submit button below.