SBI - Request for Counseling

* Denotes a required field Name of Company: * Your Name: * Company Address Line 1: * Line 2: City: * State: * Zip: * Phone: * Fax: E-mail: Web site:

Are you currently in Business? Yes    No If yes, how long? Type of Business (check all that apply) Retail   Manufacturing   Service   Dot-Com    Construction   Wholesale   Not in Business   Not for profit    Number of Employees: Full Time Part Time Brief Description of Business: How did you find out about our program or who referred you to us? Can you provide a recent balance sheet? Yes    No Can you provide a recent income statement? Yes    No

IMPORTANT! Please read before submitting application: I request to be considered for participation in the field case studies program and/or the Small Business Institute® Program at the University of Cincinnati. I understand that all information provided will be held in strict confidence by the participants of the program. I further understand that student team members agree not to: (1) recommend goods and/or services from sources in which he/she has a direct or indirect interest; and (2) accept fees or commissions for the duration of the field case project. In consideration of my participation in this teaching/learning relationship, I waive all claims against the University of Cincinnati, University of Cincinnati personnel, student team members, the Small Business Institute program, and any host or sponsoring organizations arising from this project. By submitting this form, I agree to the terms stated above. If submission does not work, please print out form and fax or mail to Dr. Charles H. Matthews, Director, SBI Program, College of Business, University of Cincinnati, Cincinnati, OH 45221-0165, phone: 513-556-7133; fax: 513-556-5499; email: ecenter@uc.edu

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