Shop Small Hawaii Membership Form

Shop Small Hawaii Membership Form

If you are a small business owner in Hawaii, please join the Shop Small Hawaii initiative by applying below. Shop Small Hawaii is free to join for all small businesses registered with the Hawaii DCCA and have a GE Tax License Number. This will take approximately 3 minutes to complete. Your information will help us to continue to provide the Shop Small Hawaii educational tools, resources, and marketing opportunities for FREE to local small businesses. ATTENTION: For assistance in registering your business or securing your GE Tax License, please contact the Patsy T. Mink Center for Business & Leadership for free business counseling at mcbl@ywcaoahu.org.
First Name*
Name only (no titles, post-nominals, etc.)
Last Name*
Name only (no titles, post-nominals, etc.)
First & Last Name
What is your current Role or Title for your business (for example: President, Managing Member, Partner):*
Gender*
Age*
Race (check all that applies)*

AsianBlackNorth AfricanMiddle EasternNative American/Alaska NativeNative Hawaiian/Pacific IslanderWhitePrefer not to sayOther Race
Hispanic Ethnicty*
Military Status*
Legal Business Name *
Is your business registered with State of Hawaii Department of Commerce & Consumer Affairs (DCCA)?*

YesNo
Business Entity Type*

Sole ProprietorshipLimited Liability Company (LLC)C CorporationS CorporationPartnershipNon-profit CorporationOther
Business Logo

Files Formats Accepted (.jpg, .png)
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Business Photos

Files Formats Accepted (.jpg, .png)
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Business Address*
City*
State / U.S. Territory*
Zip Code*
5 digit zip code
Business Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Business Email*
Business Website:
Business Related Social Media Profiles (e.g., Facebook, Instagram, Etsy, Twitter)

0/40
Please indicate the current primary industry/industries for your business*

Accommodations/Food ServicesHealth Care/Social AssistanceRetail TradeAdministrative & Support ServicesWaste Management & RemediationTransportation/WarehousingProfessional/Scientific/Technical ServicesOther ServicesFinance/InsuranceWholesale TradeReal Estate/Rental & LeasingArts, Entertainment/RecreationInformationUtilitiesEducational ServicesConstructionManagement of Companies/EnterprisesAgriculture, Forestry, Fishing/Hunting
Describe the nature of your business in 2-3 sentences. What goods or services do you offer? Example: Marketing firm focused on helping fashion designers promote their goods in Hawaii. (Do not disclose any confidential or proprietary information)*

0/30
What category best describes your product or service?*
When did your business start?*

MonthDayYear
Date
What percentage of your business is woman-owned (0-100%)?*
Total employees for your business (including yourself):*
Estimated annual revenue for previous fiscal year (We will keep this information confidential.)*
Does your business conduct transactions online (for example, offer services/goods with online purchase option)?*

YesNo
Has your business exported or is looking to export goods/services outside of the U.S.?*

YesNo
As a member of Shop Small Hawaii, receive FREE access to educational workshops and marketing opportunities to help you grow your business.
Are you interested in the following free workshops/courses? (check all that applies):*

Business analysis (e.g., business plans and operational strategies)Increasing market access (e.g., identifying and targeting new contract/procurement opportunities, RFPs, business certifications to compete for government/private contracts)Human resources for your growing businessManaging your growing businessBonding and insurance for your growing businessExporting opportunitiesAccess to capitalOther
Are you interested in the following certification courses? (check all that applies)*

Women Business Enterprise (WBE) certificationWomen-Owned Small Business (WOSB) certificationMinority Business Enterprise (MBE) certificationDisadvantaged Business Enterprise (DBE) certificationVeteran-Owned Small Business (VOSB) certification8(a) Business Development programI am not familiar with business certifications.None of the aboveOther
How did you hear about us (select all that apply):*

Chamber of CommerceCity & County of Honolulu, Office of Economic RevitalizationLenderSCORE HawaiiSmall Business Administration (SBA)Veterans Business Outreach Center of the Pacific (VBOC)Small Business Development Center (SBDC)YWCA O'ahuSocial media (for example: Facebook, Instagram, LinkedIn, Twitter)TV/Radio/Magazine/Newspaper/InternetWord of MouthOther
I permit the Shop Small Hawaii or its agent the use of my name, my business name and/or city and state, as well as my likeness, images and quotes (if any), for Business Center emails, flyers, social media, marketing or mailings to promote the Business Center's services to the community and other local businesses. PLEASE NOTE that if you select "No" below and participate in a Zoom/online platform or in-person event that is being recorded or photographed, you may need to leave the room or manually turn off your own video and name settings - this is beyond the Shop Small Hawaii's control.*

YesNo
Photograph & Video Release:

I hereby grant permission to the rights of my image, likeness and sound of my voice as recorded on audio or video tape without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area.

Photographic, audio or video recordings may be used for the following purposes:
-Conference presentations
-Educational presentations or courses
-Informational presentations
-On-line educational courses
-Educational videos
-Websites: shopsmallhawaii.com, mcblhawaii.org and ywcaoahu.org
-Facebook: @shopsmallhawaii, @mcblhawaii and LinkedIn: Shop Small Hawaii, Patsy T. Mink Center for Business and Leadership
-Newsletters for Shop Small Hawaii, the Patsy T. Mink Center for Business and Leadership and/or YWCA Oʻahu

By signing this release, I understand this permission signifies that photographic or video recordings of me may be electronically displayed via the Internet or in the public educational setting.

I will be consulted about the use of the photographs or video recording for any purpose other than those listed above.

There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed.

This release applies to photographic, audio or video recordings collected as part of MCBL programs.

By signing this form, I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for educational purposes.
Signature: My typed-in signature below acknowledges that: (1) I have submitted information in this application to the best of my knowledge; and (2) I have read and will comply with the general terms & conditions above.*
Please read the general terms & conditions below. If you are in agreement, sign where indicated.

Disclaimer: In consideration for The Patsy T. Mink Center (MCBL) Coordinating the Shop Small Hawaii and supplying data from all partners and suppliers of data compilation, the subscriber acknowledges and agrees that, to the fullest extent permitted by law, none of MCBL or the suppliers; (1) accept any responsibility or liability for the frequency of provision and accuracy of the MCBL rate or any use made by the MCBL rate by the subscriber, whether or not arising from the negligence of any of MCBL or the Suppliers; or (2) shall be liable for any loss of business or profits nor any direct, indirect or consequential loss or damage resulting from any such irregularity, inaccuracy or use of the information.

Electronic Signature: I agree that I have provided information to the best of my knowledge. I consent and agree that my use of a key pad, mouse or other device to select an item, and submit this Intake Form constitutes my signature, acceptance and agreement as if actually signed by me in writing. Further, I agree that no certification authority or other third-party verification is necessary for the validity of my electronic signature; and that the lack of such certification or third-party verification will not in any way affect the enforceability of my signature with respect to this Intake Form. This Intake Form shall be governed by and interpreted under Hawaii and federal law.
Signature: My typed-in signature below acknowledges that: (1) I have submitted information in this application to the best of my knowledge; and (2) I have read and will comply with the general terms & conditions above.*
Shop Small Hawaii Enews/Eblasts: Check the "Yes" box below if you would like to receive enews/eblasts from: Shop Small Hawaii a program of the Patsy T. Mink Center for Business and Leadership at YWCA O'ahu, 1040 Richards Street, Suite 301, Honolulu, HI, 96813 United States. Your email address will only be used for official Shop Small Hawaii purposes and will not be provided to unauthorized third-parties. Note: You can revoke your consent to receive emails at any time by clicking unsubscribe at the footer of the email or emailing Shop Small Hawaii at contact@shopsmallhawaii.com with the subject "Unsubscribe".*

YES, please keep me posted with Shop Small Hawaii enews/eblasts!No, please don't send me Shop Small Hawaii enews/eblasts at this time.
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