Sign Up for Services


Thank you for your interest in our program's services. Please select a center nearest to your location and a representative will contact you shortly upon completion of this form.
Please select your nearest center
All mandatory fields appear in bold.
First:
MI: Last:
Street Address:
City: State:
Zip Code:
 
Home Phone: Work Phone:
E-mail: Fax Number:
Yes, I would like to be included in future center mailings.
Please complete the following fields so that we may better serve you in the future. All information provided here will remain confidential.
Gender: Race:
Hispanic: Veteran:
Reservist: Disabled:
Company Status: Business Type:
Briefly describe your current or proposed company's products/services:

Please complete the following details about your company.
Company Name: Date Established:
Organization Type:
Company Gender: Company Veteran Status:
Full-Time Employees: Part-Time Employees:
Business Online? Home-based Business?
Company Web Site:
Referral From: Assistance Requested:      
Please describe specific assistance requested:
I request business management assistance from the Kentucky Small Business Development Center. I agree to cooperate should I be selected to participate in surveys designed to evaluate the Center's services. I authorize the center to furnish relevant information to the assigned management counselor(s), although I expect that information to be held in strict confidence by him/her. I further understand that all counselors have agreed not to 1) recommend goods or services from sources in which they have an interest, and 2) accept fees or commissions developing from this counseling relationship. By my signature below, and in consideration of the center's furnishing of management or technical assistance, I waive all claims against the center's personnel and its host organization. I understand that there are no warranties or assurances in connection with the counseling assistance.
Please provide your full name (First, Middle, Last) indicating your acceptance to the terms shown above.
Date: