To request counseling, fill out the information form below and send to:

Angelina College
Small Business Development Center
P.O. Box 1768
Lufkin, Texas 75902 

Name of Company:___________________________________________________________________

Your Name (Last, First, Middle): ________________________________________________________

Title:_______________________________________________________________________________ 

Telephone:_______________________________ Fax:_______________________________________

E-mail: ______________________________________

Street Address: _______________________________

City:__________________________________________ State:________

County: _______________________________ Zip Code:______________

Business Classification (Chose one):
___Retail     ___Wholesale     ___Manufacturing     ___Construction    ___Service     ___Not in Business

Business Ownership/Gender:
___Male     ___Female     ___Male/Female

Veteran Status:
___Veteran     ___Vietnam Era Vet    ___Disabled Veteran    ___Non Veteran

If you are currently in Business, Year Founded: ________

Type of Business (Use 3 to 5 words): _________________________________________________________

What type of Assistance do you desire:________________________________________________________

_________________________________________________________________________________________

Ethnic Background:
___American Indian/Alaskan Native    ___Asian/Pacific Islander      ___Black     ___White

I understand that I may use further services Sponsored by the U.S. Small Business Administration    ___Yes

PLEASE READ THE FOLLOWING BEFORE SUBMITTING INFORMATION:

    I request the free business management counseling services provided by the Small Business Administration through the Small Business Development Center.  I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA/SBDC assistance services.  I agree to provide current financial and operating data and to satisfy such other reasonable requests during the period of service on my behalf.  I authorize the SBA/SBDC to furnish relevant information to the assigned management counselor(s) although I expect that information to be held in confidence by him/her.

    I further understand that any counselor employed by the SBDC has agreed not to: (1) recommend goods or services from sources in which he/she has an interest and (2) solicit or accept fees or commissions developing from this counseling relationship.  Volunteer counselors have agreed no fee will be charged when assisting SBDC personnel.  If I request and utilize counseling services provided   by Texas Information Procurement Service (TIPS) or the Texas  Product Development Center (TPDC), certain information and technical assistance may be provided for which fees may be accepted.  If TIPS assistance results in my receiving any contract or subcontract, I will provide TIPS a signed statement containing the dollar value of each contract or subcontract, approval to validate the information, and confirmation that the contract or subcontract resulted from assistance.

    Because I am voluntarily availing myself of this service and consideration of SBA/SBDC's furnishing management or technical assistance, I release all claims against SBA personnel., SCORE, SBDC and its host organizations, SBI and other SBA resource counselors arising from this assistance.   Furthermore, I understand that no representations or promises are being made to me as to the quality of the service as voluntarily renders.  I understand that neither my counselor nor the SBDC and its host organizations are making any warranties or guaranties regarding this service.

I agree to the terms explained above.

_____________________________________________________________
Signature