Please note: The information gathered on this form is kept strictly confidential. Your information is only used by SBDC staff and NOT made public, shared or available to third parties.

Contact information: (Items with * are required)

First Name:*
Last Name: *
Business Name: *

State/Province:*   Zip:
Email Address:
Phone Number:  
Best Contact Method:
Best time for contact:

Business Information:
Currently in Business? *  
Is this a Home-based Business?*  
Describe your business:
Website Address:
Request for counseling information*
Describe the nature of the counseling you are seeking

Would you like to tell us more about yourself and/or your business? 
Fill out the optional fields below to better prepare your advisor for your meeting. 

New York State Small Business Development Center Client Disclaimer (Required)

I request management assistance from The New York Small Business Development Center. I understand that this assistance is free of charge and that I incur no obligation to The New York State SBDC or the U.S. Small Business Administration or its counselors for providing this assistance. I agree to cooperate should I be selected to participate in surveys designed to evaluate assistance services. I authorize the New York SBDC to furnish relevant information to the assigned management counselor(s) although I expect that information to be held in strict confidence to the extent allowable by law.

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 the SBDC, in cooperation with the SBA furnishing management or technical assistance, I waive all claims against The New York State SBDC, SBA, personnel or counselors arising from this assistance.