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Request for Consulting Services
PA Small Business Development Center
Environmental Management Assistance Program

Note:  This form is sent through an email.  We will then place your information into a database used solely by the Pennsylvania Small Business Development Centers.   You should receive a response to this form within 5 business days.


* Required Field

Please provide the following contact information:

Company Name *
Contact Name (first, last) *
Title (Mr., Ms., Mrs., Dr., Miss, etc)
Street Address
Address 2
City
State
Zip Code + 4 *
Work Phone
Home Phone
FAX
E-mail
URL

What is your position? (Choose one):        *

Are you the owner of the business? (Choose one): 

What is your business size? (choose one)     *

What date was (or will) your business established?  *mm/dd/yy

What is your business type? (select all that apply)    

Manufacturer                                                       
Service
Retail
Wholesale
Research and Development
Construction
Surplus Dealer
Other
Not in Business

Are you a home-based business?                       

What is your organization type? (choose one)        *

# of full-time employees  

# of part-time employees   

What is your race: (choose one)   *

What is your ethnicity: (choose one) *

Business Owner Gender:   Male   Female   Male/Female Partnership

What is your military veteran status? (choose one)   *

Are you involved in international trade?  Yes  No

What is your SBA relationship? (choose one)  

Who were you referred by? (choose one) 

Describe the product or service you do/will offer:

Are you a franchise?   Yes   No

How can EMAP assist you? (select all that apply)

Environmental Compliance/Regulatory Assistance
Energy Efficiency
Technology Development/Marketing
Permit Applications
Start-up/Acquisition
Environmental Management Strategies (EMS)
Health and Safety Requirements
Pollution Prevention/Waste Minimization
Site Visit

Describe the nature of the consulting assistance you are seeking. List the issues you feel are the most important:

 

PA SBDC CLIENT RIGHTS AND RESPONSIBILITIES

As an SBDC client you have the right to expect:
1. Consulting Assistance Provided at No Charge - Because the SBDC program is supported by funding from the U.S. Small Business Administration, the Pennsylvania Department of Community Economic Development, our university partners, and other funders, consulting is provided at no charge to you. Fees may apply for training programs, special services (such as research), materials, and publications.

2. Confidentiality of Information Provided - All SBDC representatives agree to abide by the Pennsylvania SBDC's Standards of Professional Ethics and Conflict of Interest Policy. Information you provide and the nature of your engagement will be held in strictest confidence and will not be released to the Pennsylvania Department of Environmental Protection, the U.S. Environmental Protection Agency or any other parties outside of the Pennsylvania SBDC network without your consent. Information on you will not be sold or provided to other organizations. No information you provide will be used to the commercial advantage of any SBDC representative or to the advantage of a third party.
Exceptions:
-Information about the SBDC's service delivery is reported in aggregate to its funders and the general public. Specific information about you will not be released without your consent.
-The SBDC will collect and report in aggregate to its funders and the general public information on you such as demographic statistics; size, location, age and industry of your business; the general nature of your engagement with the SBDC; and impact statistics such as financing obtained, sales increased or jobs created.
-If you were referred to the SBDC, the SBDC will notify the referrer that you have sought assistance from the SBDC. The SBDC, however, will not disclose in detail the nature of the assistance you are requesting.

3. Unbiased Recommendations - SBDC representatives will not knowingly recommend the purchase of goods or services from any individual or firm with which any SBDC representative has a financial, familial or personal interest.

4. Non-Disclosure of Trade Secrets - Sensitive trade secrets pertaining to unique facts of your business will not be used to benefit another client of the SBDC or any SBDC representative. You understand that sensitive trade secret information is information which is not obvious, which is unknown, or which is unique and pertains to new inventions, secret manufacturing and processing procedures or formulas, or any new innovative process. You understand that it is your responsibility to inform the SBDC of any such sensitive trade secrets both verbally and in writing.

5. Assistance, Guidance, Recommendations and Education - The SBDC program is an educational program. The SBDC will work with you on your specific issues to help build your management skills and knowledge. It is your responsibility to accept and implement recommendations. The SBDC will not:
-negotiate on your behalf
-write your business plan
-act as an employee of your business


As an SBDC client you are responsible for:
1. Participating in Surveys - Because this program cares about the quality of services provided, and because it is primarily funded with public support, the SBDC undertakes a number of initiatives to ascertain the quality and impact of services provided to you. Your candid feedback is critical to the long-term success of this program. You will be asked to participate in three surveys: 1) A satisfaction survey after the completion of your consulting engagement. 2) An impact survey after the close of each calendar year for the next three years. 3) A quality and impact survey conducted by an independent firm two years after the start of your consulting engagement.

2. Informing Legislators About the Service - Consulting services are provided at no charge to you because of the financial support of the federal government and the Commonwealth of Pennsylvania. To ensure the SBDC program will be available to others, we may ask you to write to your legislators to let them know about your experience with the program.

3. Accepting Responsibility and Waiving all Claims - In recognition that you are ultimately responsible for the success or failure of your business and that all decisions pertaining to implementing plans and operating your business are solely your responsibility, you hereby waive any claims of damages against the Pennsylvania SBDC program, the University of Pennsylvania, the US Small Business Administration, and the Pennsylvania Department of Community and Economic Development, based on any advice or information provided by the SBDC.

PLEASE READ THIS STATEMENT, THEN SIGN AND DATE THIS FORM

I request assistance from the PA Small Business Development Center.  I understand this assistance is free of charge.  I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA/SBDC assistance services.  I authorize the SBA/SBDC to furnish information to the assigned management consultant(s). I understand that any information disclosed is to be held in strict confidence by him/her, and that this assistance is free of charge.

I have read and understand the PA SBDC Client Rights and Responsibilities. I further understand that any consultant has agreed: (1) not to recommend goods or services from sources in which he/she has an interest, and (2) will not accept fees or commissions developing from this consulting relationship.

In consideration of SBA/SBDC furnishing management or technical assistance, I waive all claims against SBA/SBDC personnel and its host organizations arising from this assistance.

Electronic Signature: (enter your name) *    Date: *mm/dd/yy

By means of an electronic signature I understand I am agreeing to the terms listed above. 
Initials:
(enter your initials) *



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Revised:

 

 

 

 

 

 

 

 

 

 

 

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