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* 1. Type of Contact:
2. Primary Counselor:
     
PART I: Contact Information:
                                         
* 3. Client Name (Last,First,MI): (Name of the person completing the form/representative of the business)
      * User Name * First Name * Last Name    Middle Name          
      * Password          
* 4. Email:  
* 5. Client Work Phone:
      * Primary     Secondary          
6. Client Fax Number:
* 7. Street Address/PO Box (Give business address if currently in business)
* 8. City:           * County:
* 9. State: 
* 10. Zip:  
     
PART II: Demographic and Business Information
                                                                 
   11. Client Federal Representative District Number: 
   12. Client State Representative District Number:     
   13. Client State Senate District Number:                   
* 14. Race: 
* 15. Client Ethnicity:
* 16. Gender:
* 17. Do you consider yourself a person with a disability?
* 18. Veteran Status:
* 19. Referred by? (Mark all that apply):
 
19a. Referral Details (Client name, business name, website, etc):
* 20. Are you currently in Business?
Part III: Additional Data Requested
                                         
* 43. Date of Birth (mm/dd/yyyy):  
* 44. What is the highest level of education or training you have completed?
* 45. How many adults 18 years or older are in your household (including yourself)?     How many children under 18?   
* 46. Are you the head of your household?    
* 47. What is your household annual income (before taxes) last year?
* 48. Do you receive any sort of public assistance?              
               
         
* 49. Specific assistance requested:  From the following list, please indicate the reason(s) you have come to the WBDC for assistance.
       You may select up to three responses.
     
     
     
     
     
* 50. Is your business certified as a Women's Business Enterprise (WBE)? Or a Minority Business Enterprise (MBE)?    
[WBE certification is the process whereby a woman-owned company's status is verified as being at least 51% owned, managed and controlled by a woman. Certified firms may qualify for special procurement attention with public and private sectors]
CLIENT RIGHTS AND RESPONSIBILITIES


As a new client of the Women’s Business Development Center (WBDC) [including the Illinois Small Business Development Center (SBDC), Women’s Business Center (WBC), the Illinois Procurement Technical Assistance Center (PTAC), the Veterans Business Outreach Center (VBOC), and other resource partners of the U.S. Small Business Administration (SBA) and Defense Logistics Agency (DLA)], we'd like to advise you of certain rights and responsibilities you have as one of our clients:

You have a right to expect:
   1. Prompt, courteous, and professional counseling services and to be advised if the WBDC is unable to provide service within the time frame required. Be aware that due to the demand for our services, cases must often be prioritized by need and training may be recommended before counseling is provided.
   2. All information shared with the WBDC and any of its resources (staff, faculty, volunteers, and consultants) will be held in strictest confidence. No information provided by you will be used to the commercial advantage of any staff member, consultant, or other resource of the WBDC or to the benefit of any third party.
   3. That your client status with the WBDC will remain confidential. No public use of your name, address, or business identity will be made without your prior approval. Please note, however, that the WBDC is funded in part by the U.S. Small Business Administration, the Illinois Department of Commerce and Economic Opportunity, U.S. Defense Logistics Agency, City of Chicago and Cook County, and so, limited information with respect to your client status is provided to those entities.

Our role is to counsel and assist small business owners and those planning to go into business. We will not make business decisions or judgments for you, though we will make recommendations and suggestions as appropriate. These will be based upon our best efforts to apply the experience and resources available to us to assist you in making your own business decisions.

The WBDC may charge reasonable fees for training programs, special services, and publications. However, you have a right to feel secure that no fee will be charged by the WBDC or its resources for normal counseling services provided to you. Also, no recommendations will be made as to the purchase of goods or services from any individual or firm with whom any WBDC staff or its resources have any financial, familial or personal interest.

The counseling services provided to you are a part of the effort of the WBDC and its sponsors to respond to the growing needs of the small business community and to positively affect the economy of Illinois. They are not intended to compete with, replace, or be a substitute for services available from the private sector. Clients whose needs can be fully met by private sector practitioners or firms in an affordable manner will be encouraged to use those resources.

In consideration of the WBDC furnishing you with management and technical assistance, you agree to waive all claims against the WBDC and its constituent institutions, its staff, or any other resources employed by or used in connection with these services. You will also be expected to cooperate with the WBDC in its efforts to assure the quality and effectiveness of the counseling services it provides.

In this respect, the WBDC may ask all clients who receive counseling assistance to complete an evaluation of the services provided. In addition, all clients will be asked to complete an Economic Impact Verification form that documents the assistance provided by the WBDC. Finally, clients may receive direct inquiries from this office, the State Director's office or the U.S. Small Business Administration with respect to the services provided to you. Your response to all of these inquiries will be greatly appreciated.


REQUEST FOR CONSULTATION
I request business consultation service from the Small Business Administration (SBA), the Illinois Procurement Technical Assistance Center, the Illinois Small Business Development Center, and/or their resources partners at the Women’s Business Development Center (WBDC). I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA/DLA products and services. I permit the WBDC, and thereby the SBDC/SBA/DLA, the use of my name, business address and email address for surveys and information mailings regarding products and services . I understand that any information disclosed will be held in strict confidence and will not be provided to commercial entities. I authorize the WBDC to furnish relevant information to the assigned management counselor(s). I further understand that the counselor(s) agrees 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 counselor(s) furnishing management or technical assistance, I waive all claims against WBDC personnel, SBDC personnel, DLA personnel, and that of their resource partners and host organizations, arising from this assistance.
*   Client Signature     *   Date