NETWORK ACCESS SUBSCRIPTION APPLICATION

please print this form, enter your information and mail it to us
See mailing instructions at the bottom of this survey.

COMPANY NAME (if any)
BUSINESS ADDRESS

CITY STATE ZIP CODE
PHONE FAX EMAIL

NAME OF OWNER, OFFICER
OR CONTACT PERSON		 TITLE

TYPE OF BUSINESS
TYPE OF BUSINESS ENTITY: YES  CORPORATION YES  PARTNERSHIP YES  SOLE PROPRIETOR

DATE ESTABLISHED NUMBER OF EMPLOYEES

HOW DID YOU HEAR OF THE SBAC?


IF REFERRED, BY WHOM?

      Your signature below confirms your request to subscribe to the Small Business Assistance Center (SBAC) network of programs. The SBAC reserves the right to review your application for subscription eligibility. Subscription fees are non-refundable and will only be returned if your application is not accepted by the SBAC.

      Subscriptions are for a calendar year period beginning January 1st and therefore must be renewed each January 1st and are dependent upon payment of an annual subscription fee. Businesses who apply after October 31 will have their subscription fees applied to both the last quarter of the current year and the upcoming year.

AUTHORIZED SIGNATURE

TITLE DATE

ANNUAL SUBSCRIPTION FEE: $40.00
Make check payable to SBAC and mail, along with a completed application to:
SBAC, 119 E. LOCUST LANE, KENNETT SQUARE, PA 19348

(SBAC USE ONLY)

APPROVED BY DATE

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Small Business Assistance Center
119 E. Locust Lane • Kennett Square, Pa 19348 USA • Fax (610) 444-1724