Yakima Valley SCORE -

15. Describe the nature of counseling you are seeking.
16. Currently in Business? yes no	Is this a Home-based Business? yes no
17. Type of Business?
18. Name of Company?	19. How long in Business?
20. Indicate preferred date and time of appointment: Date:	Time:
I request business management counseling from the Small Business Administration. I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA assistance services. I authorize SBA to furnish relevant information to the assigned management counselor(s) although I expect that information to be held in strictest 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 of SBA's furnishing management or technical assistance, I waive all claims against SBA personnel, SCORE, SBDC and its host organizations, and other SBA resource counselors arising from this assistance. PLEASE NOTE: The estimated burden hours for the completion of this form is 7 minutes per response. If you have any questions or comments concerning this estimate or any other aspect of this information collection, please contact: Chief Administrative Information Branch, U.S. Small Business Administration, Washington, D.C. 20416 and Gary Waxman, Clearance Office, Paperwork Reduction Project (3245-0096), Office of Management and Budget, Washington, D.C. 20503.
Signature: (print Name for signature)	Date:

Please fill in or check all applicable boxes. A copy of the completed form data will be end up

in your email outbox and be transmitted to a SCORE official who will process your request.

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