Small Business - Del Mar College

Name of Company:

Point of Contact (name):

Position:

Business Owner:
Yes No

E-mail:

Web site:

Work Telephone:

Home Telephone:

Fax Number:

Business Type:

Business Size:

Organization Type:

State of Incorporation:

Mailing Address:

City:

State:

Zip Code:

County:

Disabled?

International Trade?

Federal Congressional District:

State Congressional District:

Primary Counselor:

Business Establishment Date:

Number of Employees:
Full Time:

Part Time:

Ethnic Group:

Gender:

Military Status:

SBA Client Type:

CAGE:

DUNS:

Business Status:

Miscellaneous:

Referral From:

Other:

Referral To:

Other:

Standard Industrial Classification (SICs):

Product Service Codes (PSCs):

Product/Service Description and Keywords:

NAICs:

Have you visited a center?

If so, which one:

Other Comments/Notes:

I request business management assistance from the Regional Assistance Center. I agree to cooperate should I be selected to participate in surveys designed to evaluate the Regional Assistance Center's services. I authorize the center to furnish relevant information to the assigned management counselor(s). Although I expect that information to be held in strict confidence by him/her.

I further understand that all counselors have agreed not to 1) recommend goods or services from sources in which they have an interest, and 2) accept fees or commissions developing from this counseling relationship. By my signature below, and in consideration of the center's furnishing of management or technical assistance, I waive all claims against the center's personnel and its host organization.

I understand that there are no warranties or assurances in connection with the counseling assistance.

BY ELECTRONICALLY SUBMITTING THIS REQUEST, YOU HAVE CREATED AN ACCEPTABLE "ELECTRONIC SUBSTITUTE" FOR YOUR SIGNATURE.



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