Success Story Consent Form

First name:*

Last name*

Email:*

Business name*

Street address:*

City*

State

Postal Code

What does your business sell or do?*

Who is your Business Advisor(s)?

Please provide a quote or information on how your business advisor helped you solve specific business challenges.

Phone number

Website URL

If you do not have a website, note none, or indicate expected launch date.

Social handles:

Facebook, Twitter, Instagram, etc

Release of Information for Reporting: By checking this box and submitting this form, I give permission to the LA SBDC to share information with its funders and stakeholders, including the US Small Business Administration (SBA) and the California Office of the Small Business Advocate (CalOSBA) about the advising I received from the LA SBDC Network, including information regarding business challenges and results.*

Release Form for Promotional Purposes: By checking this box and submitting this form, I hereby grant the Los Angeles Regional SBDC Network (LA SBDC) permission to use my statements, my business logo and location of my business in any and all of its publications, including but not limited to website use, advertisements, social media, email newsletters, brochures and flyers. I grant the LA SBDC Network permission to convey information related to my business for purposes of publicizing the SBDC’s programs or for any other lawful purpose. I understand that all such images and information will be made without payment or any other consideration. I am 18 years of age or older and am competent to sign a contract in my own name. I have read this release before marking, and I fully understand the contents, meaning, and impact of this release.

Full Name (Signature)*

Today's Date*

Year/Month/Day