Client Consent Form

DATABASE CONSENT FORM

ALL INFORMATION IS STRICTLY CONFIDENTIAL

Title: _____ First Name: ______Last Name: ______

Business Name: ______ABN______

Phone: ______Fax: ______Mobile: ______

Email: ______Website: ______

Address: ______

Suburb: ______Post Code: ______Council Area: ______

Date Business Started: ______Number of Owners/Operators: ______

Are you Indigenous or Torrens Strait Islander: YES / NO Business Owner Gender : Male: / Female

Applicant’s Age: ______Business Turnover: ______Number of Staff (including Owner): ______

Business Classification ~ Please tick one only
£ Agriculture / Forestry / £ Communication / £ Construction / £ Cultural & Recreation
£ Education / £ Electricity/Gas/Water / £ Finance/Insurance / £ Gov. / Defense
£ Health & Community / £ Hospitality / £ ICT / £ Manufacturing
£ Mining / £ Personal/Other / £ Property/Business / £ Retail Trade
£ Transport & Storage / £ Wholesale Trade / £ Other ______

CONSENT TO SURVEY & REPORTING INCLUSION

I consent to partaking in any survey, in order to evaluate the business services delivered by the Adelaide Business Hub (ABH). Your contact details will be protected, in line with the Information Privacy Principles contained in the Privacy Act 1988, and we will only use your details for the purpose of conducting surveys in regards to this initiative. The results of any survey will be aggregated data and will not be capable of identifying you or your organization individually.

I agree to the Adelaide Business Hub sending me emails relating to small business information and development programs.

I hereby acknowledge that ABH makes available its services on the understanding that neither the ABH staff nor the ABH are responsible for any liability or loss resulting from any of the actions or recommendations, or any failure to take action or make recommendations or to give information and/or assistance and I hereby acknowledge and discharge the ABH, its employees, contractors, servants and each of them, both jointly & severally, from all claims and demands which I may now have, or hereafter might have, against them on account of, or in any way whatsoever arising out of, or connected with, the recommendations, information and assistance provided to me.

Signature of Client: ______Date: ______

Print Name: ______

PLEASE RETURN MARKED “CONFIDENTIAL” TO (Commercial in Confidence)

Email: / OR Fax to 8440 2401

OR Post to Adelaide Business Hub, 6 Todd Street Port Adelaide SA 5015

The Services Provided by Adelaide Business Hub are partially funded by the Australian Government