Business Assistance Program Request

Electronic Request for Counseling

(To have paper forms mailed to your postal address, please contact your local office)

Request for Assistance


APPLICANT INFORMATION  

Required fields indicated with *

Salutation*
 Mr.     Ms.     Mrs.     Dr.
*
*
Business Name
*
Address2
*
*
*
*
How to contact:  
*

     OR*
 (6082631234)
 (6082631234)
 
*  
 Asian  Black  Native American/
   Alaska Native
 Native Hawaiian/
   Pacific Islander
 White  No Reply
 
*
 Yes  No  No Reply
*
 Male  Female  No Reply
*
 Yes  No  No Reply

*
*


BUSINESS INFORMATION

(Note: If you do not have a business, please select "Nascent/Not yet in business" and skip to "PRIMARY ASSISTANCE REQUESTED" below. If you currently have a business, please pick the description that best describes your business from among the following.)

*
Business Website
Business Description (50 characters)
 Conducts business online
 Is home-based
 Is 8(a) certified
NAICS (If Known)
(9999999.99)
(Numbers only-no dollar signs or commas)
(9999999.99)
  (Numbers only-no dollar signs or commas)
 Yes  No

  • If you indicated that you are in business all the information below is REQUIRED..
Business Type*
Female Ownership*
(0-100)
Business Start Date*
(mm/dd/yyyy)
Business Organization*
Number of Employees*
Full-time: Part-time:


Topic:*
 
Describe the nature of the assistance you are seeking:*
What have you done thus far to further your business and/or business idea?
 
Do you know which counselor you would like to work with? (Counselor's Name)
 

CONSULTING ASSISTANCE AGREEMENT

As a client of the Center for Technology Commercialization (CTC), I agree to:

  • Identify goals and objectives that I would like to accomplish as a result of CTC assistance.
  • Communicate honestly and openly so that goals and objectives will be accomplished and counseling will be effective.
  • Complete in a timely manner actions agreed upon between the consultant and myself to aid in achieving my goals and objectives.
  • Communicate to the consultant in advance, changes in consulting appointments.
  • Provide feedback and assessment of consulting sessions as requested via surveys or other methods.
  • Permit CTC to share my name and summary impact data with CTC financial funding sources.

As a consultant of the Center for Technology Commercialization, I agree to:

  • Keep all information confidential (excepting your name and impact data as noted above).
  • Provide feedback, advice, and guidance to aid in your success.
  • Communicate honestly and openly so that your goals and objectives will be accomplished and consulting efforts will be effective.
  • Complete in a timely manner actions agreed upon to achieve agreed upon goals and objectives.
  • Communicate to you in advance, changes in consulting appointments.

 

Request for consulting assistance

I request business consulting from the Center for Technology Commercialization. I agree to cooperate should I be selected to participate in surveys designed to evaluate our assistance services. I understand that any information received by CTC staff consultant will be held in strict confidence by the consultant to the extent allowable by law.

I further understand that CTC consultants have agreed not to: (1) recommend goods or services from sources in which the individual consultant has an interest; and (2) accept fees or commissions developing from any CTC resource partner consultants. In consideration of the provision of management and/or technical assistance by a resource partner consultant, I agree to waive all claims arising out of this assistance, against CTC personnel, the resource partner from whom I sought assistance, its host organizations, and the consultant(s) arising from this assistance.

Please accept by typing your full name here and clicking Submit: *

 
©2009 Center for Technology Commercialization