Course Application - IMPACT

Comments

This field is for validation purposes and should be left unchanged.

Thank you for your interest in our program's services. To begin, please enter your name and e-mail address below.

SBDC services are provided in a nondiscriminatory way to all legal residents and citizens in the US.

Name(Required)

First Last

Email(Required)

We use this to contact you and to check whether you already have a record with us.

Contact Information

A few more details so a counselor can get in touch.

Phone Number(Required)

Cell Phone

Address

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Details

These questions are optional and are used only for federal reporting. Every question includes a "Prefer not to say" option.

Sex

LGBTQ+

Race

Additional races

Native American

Asian

Black or African American

Native Hawaiian or Pacific Islander

White/Caucasian

Alaska Native

Middle Eastern

North African

Select any that also apply.

Hispanic Origin

Veteran Status

Military Reserve Status

Do you consider yourself a person with a disability?

Company Address

Company Address(Required)

Street Address Address Line 2 City State ZIP Code

Mailing address is the same as physical address?

Yes, use the company address above for mail

Company Mailing Address

Street Address Address Line 2 City State ZIP Code

Missouri

SBIR Award Status

Products/Services

Industry (NAICS code)(Required)

Start typing what your business does, for example "food truck" or "bookkeeping", then choose the closest match. If you already know your six-digit NAICS code you can type that instead.

Product or Service Description(Required)

Relationship

Position

Are you the business owner?

Yes, I am the business owner

I request training and/or business counseling service from Missouri APEX Accelerators (Missouri APEX), funded through the Department of Defense (DoD) and/or the Missouri Small Business Development Center (Missouri SBDC), funded through Small Business Administration (SBA) or an SBA Resource Partner. I agree to cooperate should I be selected to participate in surveys designed to evaluate these services, impact, and/or make improvements on services. I permit SBA/DoD or its agent the use of my name and address for SBA/DoD surveys and information mailings regarding SBA/DoD products and services. I understand that any information disclosed will be held in strict confidence. DoD and SBA will not provide your personal information to commercial entities. I authorize SBA/DoD 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 SBA/DoD personnel, and that of its Resource Partners and host organizations, arising from this assistance.

Please note: The estimated burden for completing this form is 3 minutes. Comments on the burden should be sent to: U.S. Small Business Administration, 409 3rd Street, SW, Washington, DC 20416, and to: Desk Officer SBA, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C., 20503. OMB Approval (3245-0324). PLEASE DO NOT SEND FORMS TO OMB.

I certify that I am legally authorized to receive taxpayer-funded assistance under federal law. I understand that pursuant to Executive Order 14218 (February 19, 2025), the Missouri Small Business Development Center is prohibited from providing services funded by taxpayer dollars to individuals not lawfully present in the United States. I affirm that the information provided is accurate.

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

Course Application – Impact Scholarship

FAQs

Contact Information

Address

Details

Company Information

Company Address

Missouri

Products/Services

Relationship

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