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2. Instructions

   Please fill out this form as completely as possible, and sign and date the bottom of the form.

4. Client Name
5. Business Name
7. Address
9. City
10. State
11. Zip Code
12. County
14. Phone Number
15. Email
16. Website
18. Briefly describe the product or service your business offers.
20. Are you a veteran or active duty military?

    1. Yes
    2. No
21. Business Owner Ethnic Group
    -- Select One --AsianBlack/African AmericanHispanicNative American/Alaska NativeNative Hawaiian/Pacific IslanderWhiteTwo or More RacesOther
23. Business Stage

    1. Conceptual (only an idea)
    2. Growth (business is steady and looking to expand)

    1. Startup (business is in the early stages)
    2. Survival (experiencing problems with business)
25. How did you find out about us?

    1. Advertising
    2. Bank
    3. Chamber of Commerce
    4. Client/Word of Mouth
    5. College or University
    6. Internet

    1. SBA
    2. SBTDC
    3. Trade and Commerce
    4. Workshop
    5. GDBCC
    6. Other
26. If Other
28. Please describe your current business issues, including any specific questions you may have.
30. Provide any additional background information, if applicable.
32. Would you like to sign up for our small business email newsletter?

    1. Yes
    2. No
34. Applicant Must Sign and Date

    I request business assistance from the City of Durham in identifying entrepreneurial support agencies to provide technical assistance and counseling to my small business entity. I authorize the City of Durham to furnish relevant information to the referred support agencies and their small business counselor(s), although I expect that information to be held in strict confidence.

    
    

    The City of Durham will not accept fees or commissions developing from this counseling relationship. In consideration of furnishing management or technical assistance, I waive all claims against the City of Durham, entrepreneurial support agencies, and any other resource counselors arising from this assistance.

36. Signature
37. Date
    Date
Leave This Blank:


39. 1. Receive an email copy of this form.
40. Email address

    This field is not part of the form submission.

41. Submit

* indicates a required field