Martin County eda

Name

Email Address

Address

City

State

Zip

Phone

Please include me in future email notifications about upcoming events and important announcements. Please include me in future email notifications about upcoming events and important announcements. Yes No

Gender Gender Male Female

Race Race Alaskan Native Asian Black or African American White/Caucasian Hispanic or Latino Native American Native Hawaiian or Pacific Islander Choose not to respond

Hispanic Origin Hispanic Origin Hispanic Non-Hispanic Choose not to respond

Do you consider yourself a person with a disability? Do you consider yourself a person with a disability? Yes No

Veteran Status Veteran Status Non-Veteran Veteran Service-Disabled Veteran

Military Status Military Status Active Duty Choose not to respond Military Spouse National Guard National Guard - Active Duty None Reservist Reservist - Active Duty

Referred by Referred by SBDC Lender Website SCORE Other Client Educational Institution Local Economic Development Official Chamber of Commerce Magazine/Newspaper Word of Mouth Other

Are you currently in business? Are you currently in business? Yes No

What is the nature of the counseling you are seeking? What is the nature of the counseling you are seeking? Start-up assistance Business plan Financing/Capital Managing a business Human Resources/Managing Employees Customer Relations Business Accounting/Budget QuickBooks assistance Cash Flow Management Tax Planning Marketing/Sales Government Contracting Franchising Buy/Sell a business Technology/Computers eCommerce Legal Issues International Trade

Please describe specific assistance requested:

Best method to reach you? Best method to reach you? Email Phone

Best day/time to meet:

Please read the following Terms/Conditions and Privacy Policy and indicate your acceptance. This is a requirement for requesting services from RCEF. Thank you. The information requested on the Request for Counseling Form (SBA Form 641) will assist the Regional Center for Entrepreneurial Facilitation (RCEF) in serving you and responding to sponsors' requests for information about RCEF performance. As a matter of law, RCEF may not disclose the name, address, or telephone number of any individual or small business concern receiving assistance without the consent of such individual, unless specifically instructed to do so under court order or required by law. Except for signing this form, you are not required to provide any of the requested information as a condition of receiving service. Other non-personal information you provide may be considered public. Please read the notices below for important information concerning data collected and used by the U.S. Small Business Administration (SBA). By signing this form, you agree, if selected, to participate in surveys designed to evaluate the services and impact of the services offered by RCEF. Any information disclosed in such surveys will be held in strict confidence. RCEF WILL NOT PROVIDE PERSONAL INFORMATION TO COMMERCIAL OR OTHER THIRD PARTY ENTITIES UNLESS REQUIRED TO BY LAW. If you elect not to participate in surveys to measure RCEFs effectiveness and informational mailings, please inform your Professional Business Consultant who will have your name removed from the survey list. By signing this form, the applicant certifies, that neither they nor their principals are presently debarred, suspended, proposed for disbarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency. By signing this form, you further understand that RCEF counselors are prohibited from: (1) recommending goods or services from sources in which the counselor has an interest and (2) accepting fees or commissions developing from the counseling relationship. In consideration of the counselor furnishing management or technical assistance, you waive all claims against the U.S. SBA and its resource partners, any of its independent contractors and host organizations, and their personnel, arising from the assistance. Notification of Federal and State Laws Pertaining to Data Collection and Use of Data: To comply with legislation passed by the Congress and Executive Orders issued by the President, Federal executive agencies, including the SBA, must notify you of certain information. You can find the regulations and policies implementing these laws and Executive Orders in Title 13, Code of Federal Regulations (CFR), Chapter 1, or SBAs Standard Operating Procedures (SOPs). In order to provide the required notices, the following is a brief summary of the various federal laws and Executive Orders that affect SBAs entrepreneurial development programs. Paperwork Reduction Act (44 U.S.C. § 3501): RCEF funded in part by the U.S. SBA, is collecting the information on this form in order to facilitate business assistance services to its clients and for agency analysis related to the operation and management of its entrepreneurial development programs. Periodically, the SBA may use some of the non-personal information collected on this form to produce summary reports for program and management analysis, as required by law. SBA also intends to use the individual client data to select participants for follow-up surveys designed to evaluate SBA assistance services. PLEASE NOTE: The estimated burden for completing this information is 18 minutes. Your responses to the requested information are voluntary under these programs. If you have questions or comments concerning any aspect of this information, please contact the U.S. SBA Information Branch, Washington, DC 20416 and/or Desk Officer for the SBA, Office of Management and Budget, Office of Information Regulatory Affairs, 725 17th St. NW, Washington, DC 20503. Privacy Requirements (15 U.S.C § 648(a)): This law provides that RCEF may not disclose the name, address, or telephone number of any individual or small business concern receiving assistance under 21(a) of the Small Business Act without the consent of such individual or small business concern, unless ordered to make such a disclosure by a court or for program audit purposes. In such cases, such information is highly restricted in its use. Freedom of Information Act (5 U.S.C. § 552): This law provides, with some exceptions, that SBA must supply information in its files and records to a person requesting it. This generally includes statistical data on SBAs business assistance programs, including RCEF, which are in aggregate. SBA does not make available a client's proprietary data without first doing pre-notification, as required by Executive Order 12600, or provide information that would cause competitive harm or constitute a clearly unwarranted invasion of personal privacy. Address a request under this Act to the appropriate SBA office and identify it as a Freedom of Information Act request. For information about the Freedom of Information Act, contact Chief, Freedom of Information/Privacy Act Office, U.S. Small Business Administration, 409 3rd St. SW, Suite 5900, Washington, DC 20416. Minnesota Data Practices Act (Minnesota Statutes Chapter 13). Under the Minnesota Data Practices Act, all information collected by government entities, including RCEF, is public unless a specific law classifies it otherwise. RCEF does not, as a matter of practice, disclose client information to third parties. You should be aware, however, that information you supply while a client of RCEF may be considered public information under the Minnesota Data Practices Act and may need to be disclosed if a Data Practices Act request is made. Information you supply while a client of RCEF will be used by the counselor during the counseling relationship and may be aggregated with data supplied by other clients to produce statistical reports. Individuals or specific business information will not be identified in such reports. You are not legally required to supply the requested information, although your failure to fully disclose pertinent information may affect the outcome of the counseling. Please read the following Terms/Conditions and Privacy Policy and indicate your acceptance. This is a requirement for requesting services from RCEF. Thank you. The information requested on the Request for Counseling Form (SBA Form 641) will assist the Regional Center for Entrepreneurial Facilitation (RCEF) in serving you and responding to sponsors' requests for information about RCEF performance. As a matter of law, RCEF may not disclose the name, address, or telephone number of any individual or small business concern receiving assistance without the consent of such individual, unless specifically instructed to do so under court order or required by law. Except for signing this form, you are not required to provide any of the requested information as a condition of receiving service. Other non-personal information you provide may be considered public. Please read the notices below for important information concerning data collected and used by the U.S. Small Business Administration (SBA). By signing this form, you agree, if selected, to participate in surveys designed to evaluate the services and impact of the services offered by RCEF. Any information disclosed in such surveys will be held in strict confidence. RCEF WILL NOT PROVIDE PERSONAL INFORMATION TO COMMERCIAL OR OTHER THIRD PARTY ENTITIES UNLESS REQUIRED TO BY LAW. If you elect not to participate in surveys to measure RCEFs effectiveness and informational mailings, please inform your Professional Business Consultant who will have your name removed from the survey list. By signing this form, the applicant certifies, that neither they nor their principals are presently debarred, suspended, proposed for disbarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency. By signing this form, you further understand that RCEF counselors are prohibited from: (1) recommending goods or services from sources in which the counselor has an interest and (2) accepting fees or commissions developing from the counseling relationship. In consideration of the counselor furnishing management or technical assistance, you waive all claims against the U.S. SBA and its resource partners, any of its independent contractors and host organizations, and their personnel, arising from the assistance. Notification of Federal and State Laws Pertaining to Data Collection and Use of Data: To comply with legislation passed by the Congress and Executive Orders issued by the President, Federal executive agencies, including the SBA, must notify you of certain information. You can find the regulations and policies implementing these laws and Executive Orders in Title 13, Code of Federal Regulations (CFR), Chapter 1, or SBAs Standard Operating Procedures (SOPs). In order to provide the required notices, the following is a brief summary of the various federal laws and Executive Orders that affect SBAs entrepreneurial development programs. Paperwork Reduction Act (44 U.S.C. § 3501): RCEF funded in part by the U.S. SBA, is collecting the information on this form in order to facilitate business assistance services to its clients and for agency analysis related to the operation and management of its entrepreneurial development programs. Periodically, the SBA may use some of the non-personal information collected on this form to produce summary reports for program and management analysis, as required by law. SBA also intends to use the individual client data to select participants for follow-up surveys designed to evaluate SBA assistance services. PLEASE NOTE: The estimated burden for completing this information is 18 minutes. Your responses to the requested information are voluntary under these programs. If you have questions or comments concerning any aspect of this information, please contact the U.S. SBA Information Branch, Washington, DC 20416 and/or Desk Officer for the SBA, Office of Management and Budget, Office of Information Regulatory Affairs, 725 17th St. NW, Washington, DC 20503. Privacy Requirements (15 U.S.C § 648(a)): This law provides that RCEF may not disclose the name, address, or telephone number of any individual or small business concern receiving assistance under 21(a) of the Small Business Act without the consent of such individual or small business concern, unless ordered to make such a disclosure by a court or for program audit purposes. In such cases, such information is highly restricted in its use. Freedom of Information Act (5 U.S.C. § 552): This law provides, with some exceptions, that SBA must supply information in its files and records to a person requesting it. This generally includes statistical data on SBAs business assistance programs, including RCEF, which are in aggregate. SBA does not make available a client's proprietary data without first doing pre-notification, as required by Executive Order 12600, or provide information that would cause competitive harm or constitute a clearly unwarranted invasion of personal privacy. Address a request under this Act to the appropriate SBA office and identify it as a Freedom of Information Act request. For information about the Freedom of Information Act, contact Chief, Freedom of Information/Privacy Act Office, U.S. Small Business Administration, 409 3rd St. SW, Suite 5900, Washington, DC 20416. Minnesota Data Practices Act (Minnesota Statutes Chapter 13). Under the Minnesota Data Practices Act, all information collected by government entities, including RCEF, is public unless a specific law classifies it otherwise. RCEF does not, as a matter of practice, disclose client information to third parties. You should be aware, however, that information you supply while a client of RCEF may be considered public information under the Minnesota Data Practices Act and may need to be disclosed if a Data Practices Act request is made. Information you supply while a client of RCEF will be used by the counselor during the counseling relationship and may be aggregated with data supplied by other clients to produce statistical reports. Individuals or specific business information will not be identified in such reports. You are not legally required to supply the requested information, although your failure to fully disclose pertinent information may affect the outcome of the counseling. I have read the Terms/Conditions and Privacy Policy stated above.

Enter your name (First, Middle, Last) indicating your acceptance of the Terms and Conditions stated above.