I request business-counseling service from the Small Business Administration SBA or an SBA Resource Partner. I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA services. I permit SBA or its agent the use of my name and address for SBA surveys and information mailings regarding SBA products and services Yes No I understand that any information disclosed will be held in strict confidence. SBA will not provide your personal information to commercial entities I authorize SBA to furnish relevant information to the assigned management counselors I further understand that the counselors 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 counselors furnishing management or technical Assistance, I waive all claims against SBA personnel, and that of its Resource Partners and host organizations, arising from this Assistance. Please note: The estimated burden for completing this form is 3 minutes. You are not required to respond to any collection information unless it displays a currently valid OMB approval number. Comments on the burden should be sent to: U.S. Small Business Administration, 409 3rd Street, SW, Washington, DC 20416, and to: Desk Officer SBA, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C., 20503. OMB Approval 3245-0324 PLEASE DO NOT SEND FORMS TO OMB. SBDC services are not available to individuals or entities that have been debarred or suspended by the federal government. By agreeing to receive assistance from the SBDC with your signature on this form, you are self-certifying that you are not currently federally debarred or suspended and also agree to cease using SBDC services if you become federally debarred or suspended in the future.