Company name ___________________________

Company Street Address ___________________________________________

City ________________ State _________________ Zip _____________ County _________________

Company Phone __________________ Fax ____________________ e-mail ______________________

Business Type (check one)

____ Retail

____ Wholesale

____ Service

____ Manufacturing

____ Construction

____ Other (identify/Describe _____________________________________________________________

Indicate briefly, the nature of services and/or consulting you are seeking:

Area of consulting to be provided (To be filled-out by the consultant)

____ Business Start-up/Acquisition ____ Engineering/R&D

____ Capital Sources ____ Personnel

____ Marketing/Sales ____ Computer Systems

____ Government Procurement ____ International Trade

____ Accounting & Records ____ Business Liquidation/Sale

____ Financial Analysis/Cost Control ____ Inventory Control

I request business management consulting from Wingate University. I agree to cooperate should I be selected to participate in surveys designed to evaluate assistance services. I authorize Wingate University School of Business & Economics to furnish relevant information to the assigned consultant(s) although I expect that information to be held in strict confidence by him/her.

I further understand that any consultant 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 consulting relationship. In consideration of Wingate University’s furnishing management or technical assistance, I waive all claims against SBA personnel, SCORE, SBDC and its Host organizations, SB ™, and other SBA Resource Counselors arising from this assistance.

______________________________________ Date _______________________

Signature and Title of Requester

____ word of mouth ____ chamber of commerce ____ other (identify) ________________________