You can always press Enter⏎ to continue
Jackson Ward Collective® Membership Application
1
Name
*
This field is required.
First Name
Last Name
Previous
Next
Submit
Press
Enter
2
Address
*
This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Previous
Next
Submit
Press
Enter
3
Email
*
This field is required.
example@example.com
Previous
Next
Submit
Press
Enter
4
Do you identify as Black or African-American?
*
This field is required.
Yes
No
Previous
Next
Submit
Press
Enter
5
What is the name of your (primary) business?
*
This field is required.
Previous
Next
Submit
Press
Enter
6
How long have you been in business?
*
This field is required.
Please Select
I have not yet launched, but I have a business idea
1-2 years
3-4 years
5-7 years
8-10 years
11-15 years
over 15 years
Please Select
Please Select
I have not yet launched, but I have a business idea
1-2 years
3-4 years
5-7 years
8-10 years
11-15 years
over 15 years
Previous
Next
Submit
Press
Enter
7
What is your business idea?
*
This field is required.
Previous
Next
Submit
Press
Enter
8
Where is your business located?
*
This field is required.
Please Select
Charles City County
Chesterfield County
Colonial Heights
Dinwiddie County
Emporia
Hanover County
Henrico County
Hopewell
Goochland County
Greenvsviille County
Henrico County
New Kent County
Petersburg City
Powhatan County
Prince George County
Richmond City
Surry County
Sussex County
Outside of the Richmond Region
Please Select
Please Select
Charles City County
Chesterfield County
Colonial Heights
Dinwiddie County
Emporia
Hanover County
Henrico County
Hopewell
Goochland County
Greenvsviille County
Henrico County
New Kent County
Petersburg City
Powhatan County
Prince George County
Richmond City
Surry County
Sussex County
Outside of the Richmond Region
Previous
Next
Submit
Press
Enter
9
Have you registered your business with the State Corporation Commission?
*
This field is required.
Yes
No
Previous
Next
Submit
Press
Enter
10
Do you have your business license in the locality where your business is located?
*
This field is required.
Yes
No
Previous
Next
Submit
Press
Enter
11
What industry does your business fall under?
*
This field is required.
Please Select
Creatives
Hospitality
Personal Services
Professional Services
Retail
Please Select
Please Select
Creatives
Hospitality
Personal Services
Professional Services
Retail
Previous
Next
Submit
Press
Enter
12
What is your primary reason for seeking to join The Jackson Ward Collective®?
*
This field is required.
Please Select
To be a part of something bigger than myself
To get access to resources to help me navigate growing a business
To connect with other Black entrepreneurs
To participate in networking events
To obtain funding for my business
Please Select
Please Select
To be a part of something bigger than myself
To get access to resources to help me navigate growing a business
To connect with other Black entrepreneurs
To participate in networking events
To obtain funding for my business
Previous
Next
Submit
Press
Enter
13
What is your secondary reason for seeking to join The Jackson Ward Collective®?
*
This field is required.
Please Select
To be a part of something bigger than myself
To get access to resources to help me navigate growing a business
To connect with other Black entrepreneurs
To participate in networking events
To obtain funding for my business
Please Select
Please Select
To be a part of something bigger than myself
To get access to resources to help me navigate growing a business
To connect with other Black entrepreneurs
To participate in networking events
To obtain funding for my business
Previous
Next
Submit
Press
Enter
14
Are you looking for any of the following resources (check all that apply)?
*
This field is required.
Banker
Attorney
CPA or Accountant
Business Coach
Accountability Partner
Brand and/or Marketing Support
Investors
Grant Funding
None of the Above
Other
Previous
Next
Submit
Press
Enter
15
Business web address
*
This field is required.
If none, type none at this time
Previous
Next
Submit
Press
Enter
16
Business email address
*
This field is required.
example@example.com
Previous
Next
Submit
Press
Enter
17
Brief description of your business's products or services
*
This field is required.
Previous
Next
Submit
Press
Enter
18
IG Handle
*
This field is required.
Use format @thejwcfoundation. If none, type "none"
Previous
Next
Submit
Press
Enter
19
Facebook
*
This field is required.
Use format www.facebook.com/thejwcfoundation. If none, type "none"
Previous
Next
Submit
Press
Enter
20
LinkedIn
*
This field is required.
Use format https://www.linkedin.com/company/thejwcfoundation. If none, type "none"
Previous
Next
Submit
Press
Enter
21
X (formerly known as Twitter)
*
This field is required.
Use format @jwcfoundationva. If none, type "none"
Previous
Next
Submit
Press
Enter
22
Business Logo or Headshot
*
This field is required.
Drag and drop files here
Select files to upload
Max. file size
: 1.0MB
Browse Files
Please provide in a hi-res format, either JPEG or PNG. Business logo is preferred, but if you do. not have one, please provide a headshot.
Cancel
of
Previous
Next
Submit
Press
Enter
23
Would you like the information for the Member Only Directory to be included in a public Member Directory on our website?
The purpose of the public member directory is to provide a free marketing opportunity for your business. If you are not ready to share your business with the world, no worries! You can always opt in at a later time when you're ready!
YES
NO
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
23
See All
Go Back
Submit