REQUEST FOR COUNSELING

Any field marked with any asterisk (*) must be filled out for this form to be valid.

Name of Company*
Point of Contact*

Position*

Business Owner *
Mailing Address*
City*
State*
Zip Code *
Country*

Work Telephone *


Alternate Phone *

FAX Number *

E-mail *

Website

Ethnic Group*






Gender*

Military Status*




SBA Client Type









Primary Counselor:

David A. Talbot

Year Business was Established* Number of Employees*





Business Size*

Business Type*










Organization Type*
Enter your Tax ID Number here*
International Trade

 		Disabled Federal Congressional District

 State Representative District

Business Status (Select all that applies)







Referral From

Referral To

















Standard Industrial Classifications (SICs)
 Product/Service Codes (PSCs)
 No. Amer. Indust. Class. Sys. (NAICSs)
Product/Service Description and Keywords*
Have you visited another center?            If so, which one?
Other Comments/Notes

I understand that in return for the information and assistance provided by the South Suburban College Procurement Technical Assistance Center, and the Illinois Small Business Development Center Network, that I am responsible to report any bids on any government work on a monthly basis.  In addition, I am to provide the Procurement Technical Assistance Center with any information concerning contracts awarded to my firm, including but not limited to:

The above shall apply to sub-contracts traceable to government sources, also.