eCenter Direct - Request For Services

Massachusetts SBDC/PTAC: Sign-up For Services Thank you for your interest in our program's services. Please complete this form and a representative will contact you shortly.

All mandatory fields appear in bold.

Salutation:

First:

MI:

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Street Address:

City:

State:

Zip Code:

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E-mail:

Fax Number:

Yes, I would like to be included in future center e-mailings.

Please complete the following fields so that we may better serve you in the future. All information provided here will remain confidential.

Gender:

Hispanic:

Veteran:

Reservist:

Disabled:

Company Status:

Business Type:

Briefly describe your current or proposed company's products/services:

PSCs:

NAICSs:

Please complete the following details about your company.
Company Name:		Date Established:
Organization:		State of Incorporation:
Business Size:
Company Gender:		Company Veteran Status:
Full-Time Employees:		Part-Time Employees:
Business Online?		Home-based Business?
Federal ID:
DUNS Number:
CAGE Code:
Gross Revenue/Sales ($):		Gross Sales Date:
Company Web Site:

Referral From:

Assistance Requested:

Please describe specific assistance requested:

I request free and confidential government contracting assistance from the Massachusett Procurement Technical Assistance Center (PTAC). I agree to respond to quarterly surveys to be considered an active PTAC client. I authorize the center to furnish relevant information to the assigned procurement advisor(s), although I expect that information to be held in strict confidence by him/her. I also agree not to resell electronic bidmatching information, specifications/standards, etc. as a recipient of PTAC services.

I further understand that all procurement advisors 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 advisory relationship. By my signature below, and in consideration of the center's furnishing of government contracting technical assistance, I waive all claims against the center's personnel and its host organization - Massachusetts Small Business Development Center (MSBDC) Network, headquartered at the University of Massachusetts/Amherst.

I understand that there are no warranties or assurances in connection with the government contracting advisory services.

Please provide your full name (First, Middle, Last) indicating your acceptance to the terms shown above.

Massachusetts SBDC/PTAC: Sign-up For Services