Name *

First Name

Last Name

Primary Phone *

(###)

###

####

Cellphone

(###)

###

####

Home Phone

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

This will be used for statistical purposes only and will not be shared.

MM

DD

YYYY

How did you hear of SOURCE? (mark all that apply) *

SBA District Office

Lender

Source Website

ISBDC

SCORE

Education Institution

Local Economic Development

Indy Chamber

Internet

Magazine/Newspaper

Television/Radio

Other Client

Choose your type of business. *

Select one category.

Professional, Scientific & Technical Services

Manufacturing

Finance and Insurance

Information

Construction

Retail Trade

Real Estate and Rental Leasing

Health Care & Social Assistance

Wholesale Trade

Public Administration

Educational Services

Management of Companies & Enterprises

Agriculture, Forestry, Fishing & Hunting

Accommodation & Food Services

Arts, Entertainment & Recreation

Transportation & Warehousing

Administrative & Support

Waste Management & Remediation Services

Other Services

Choose which areas you would like to be mentored in. *

Choose however many categories you wish.

Start-Up Assistance

Technology/Computers

Customer Relations

Financing/Capital

Managing a Business

Tax Planning

Managing Employees

Government Contracting

Business Accounting/Budget

Cash Flow Management

Human Resources/Employees

eCommerce

Buy/Sell Business

Legal Issues

Marketing/Sales

Business Plan

Franchising

Other

I request business counseling service from the SOURCE River West Center. I agree to cooperate should I be selected to participate in surveys designed to evaluate SOURCE River West services. I permit SOURCE River West or its agent the use of my name and address for SOURCE River West surveys and information mailings regarding SOURCE River West mentoring. I also understand that any information disclosed will be held in strict confidence (SOURCE River West will not provide your personal information to commercial entities). I authorize SOURCE River West to furnish relevant information to the assigned management counselor(s). I further understand that the counselor(s) 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 counselor(s) furnishing management or technical assistance, I waive all claims against SOURCE River West personnel, and that of its SOURCE River West Partners and host organizations, arising from this assistance. *

Please accept the terms and conditions in order for this form to be processed.

I accept these terms and conditions