SCORE
REQUEST FOR COUNSELING

SCORE
151 Patton Avenue
Asheville NC 28801-5007
Phone: 828-271-4786 Fax: 828-271-4786
Your Name
Home Phone Bus.Phone
E-mail Address Fax
Street Address
City State Zip
How did you hear about SCORE?
Describe the nature of the counseling you are seeking:
Are you currently in business?   Yes   No    
If yes, what type of business?            
Name of business            
Business ownership?   Male   Female   Both
Veteran Status?   Veteran   Vietnam-era   Disabled
Ethnic Background - race?   Native Amer   Asian/Pac
    Black   White    
Ethnic background-Ethnicity   Hispanic   Non-Hispanic    
             

I understand that all counselors have agreed not to: (1) recommend goods or services from sources in which he/she has an interest, (2) accept fees or commissions developing from this counseling relationship and (3) all information disclosed by client to be held in strict confidence by any SCORE counselor. In consideration of the counselor(s) furnishing management or technical assistance I waive all claims aggainst SBA personnel, SCORE and its host organizations, and other SBA Resource Counselors arising from this assistance.

Sign your name:____________________________________________________

Date:______________________

Note: a counselor will be assigned as soon as this form is received and he or she will contact you shortly thereeafter to set up an apppointment.