Name *
Name
Primary Phone *
Primary Phone
Cellphone
Cellphone
Home Phone
Home Phone
Address *
Address
Select whichever applies.
Select whichever applies.
Select whichever applies.
Select whichever applies.
Select your highest educational level.
Date of Birth *
Date of Birth
This will be used for statistical purposes only and will not be shared.
How did you hear of SOURCE? (mark all that apply) *
Choose your type of business. *
Select one category.
Choose which areas you would like to be mentored in. *
Choose however many categories you wish.
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.