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Center For Technology Commercialization

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For all of the following questions, please answer regarding the existing or planned business that you would like consulting for.

First Name
Last Name
Zip Code	Enter your 5 digit Zip Code. If you don't have one or don't know your zip code, enter 00000

Business Name	Leave blank if you do not have a name chosen or the business name is the same as your name.
Position	Your position or title related to this business
Address	Your physical street address (number and street) of the business. If a home based business, or the business has not started yet, use your home address.
Address Line 2	Optional. Use if you need additional address postal information like apt, floor, suite, etc., or a PO box.
City
State

Please enter contact information regarding this business so that we may contact you if necessary

Primary Phone	The best phone number (with area code) to reach you during our standard business hours. Include extension if necessary.
Primary Phone Type	Type of the primary phone above
Secondary Phone	A secondary phone number to contact you, if we cannot reach you at the primary number.
Secondary Phone Type	Type of the secondary phone above

Web Site	Web site URL for the business
Business Description	Brief three to five word description of the business

Please answser the following demographic questions about yourself.

Race	White Black Asian Native American/Alaskan Hawaiian/Pacific Check any that apply
Hispanic Ethnicity
Gender
Disability	Do you consider yourself a person with a disabilty
Military Status

Business Status

Business has started

Check if you have fully established your business and currently have operations in place. Leave unchecked if you are in the planning stages and have not yet fully started this business.

Since this business has started, please enter the following information.

Year Started	Year this business started
Month Started	Month this business started
Business Type	Primary category of business
Female Ownership %	% Enter the percent female ownership for this business.
Business Online	Yes If business is conducted online
Home Based Business	Yes If business is home based
8(a) Certified	Yes If you are currently 8(a) certified.

Business Organization

Legal entity of the business

Employees FT

Current Number of Full Time Employees

Employees PT

Current Number of Part Time Employees

Annual Sales $

Annual Sales $ for the most recent full business year

Annual P/L $

Annual Profit/Loss $ for the most recent full business year

Are you currently exporting

Yes

Export Employees	Current Number of Total Export Related Employees
Export Sales $	Export Related Sales for most recent full business year
Export Countries	Countries you are currently exporting to. Start typing the name of the country and a list will appear to choose from. You may select more than one.

If you have already contacted or worked with an CTC consultant, please fill name in here.
How did you hear about us?
The 3 most important areas of consulting you are interested in.	Adv/Promo Business Planning Buy/Sell a Business COVID-19 Disaster Loan COVID-19 General Support Distribution Management E-Commerce Financial Management Financing Government Grant Government Procurement Human Resources Management International Business Internet Marketing Legal Issues Licenses/Permits Marketing New Product Development Quickbooks Sales Skills/Management SBIR/STTR Grant Starting a Business Strategic Planning Taxes Technology/Fast Growth Web Design Women in Business
Please describe what you want to accomplish in regard to the areas of consulting you checked above.

Please read the following, enter your Full Name, and click Continue below to indicate your acceptance.

As a client of the Center for Technology Commercialization (CTC), I agree to:

Identify goals and objectives that I would like to accomplish as a result of CTC assistance.
Communicate honestly and openly so that goals and objectives will be accomplished and counseling will be effective.
Complete in a timely manner actions agreed upon between the consultant and myself to aid in achieving my goals and objectives.
Communicate to the consultant in advance, changes in consulting appointments.
Provide feedback and assessment of consulting sessions as requested via surveys or other methods.
Permit CTC to share my name and summary impact data with CTC financial funding sources.

As a consultant of the Center for Technology Commercialization, I agree to:

Keep all information confidential (excepting your name and impact data as noted above).
Provide feedback, advice, and guidance to aid in your success.
Communicate honestly and openly so that your goals and objectives will be accomplished and consulting efforts will be effective.
Complete in a timely manner actions agreed upon to achieve agreed upon goals and objectives.
Communicate to you in advance, changes in consulting appointments.

I request business consulting from the Center for Technology Commercialization. I agree to cooperate should I be selected to participate in surveys designed to evaluate our assistance services. I understand that any information received by CTC staff consultant will be held in strict confidence by the consultant to the extent allowable by law.

I further understand that CTC consultants have agreed not to: (1) recommend goods or services from sources in which the individual consultant has an interest; and (2) accept fees or commissions developing from any CTC resource partner consultants. In consideration of the provision of management and/or technical assistance by a resource partner consultant, I agree to waive all claims arising out of this assistance, against CTC personnel, the resource partner from whom I sought assistance, its host organizations, and the consultant(s) arising from this assistance.

Please enter your full name, indicating your acceptance of the above terms.

Full Name:

Date: 9/22/2023 5:53:02 PM

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