Women's Business Launch (WBL) Program Application Form
Thank you for applying for the Women's Business Launch (WBL) Program!
We will review your application and get back to you regarding next steps. Please note we can only accept applicants from Ontario.
PERSONAL & CONTACT INFORMATION
First Name
*
First Name
Last Name
*
Surname
Age range
*
18-29
30-45
46-54
55+
Email
*
example@example.com
Cell Phone
*
Please enter a valid phone number.
Home/Other Phone
Please enter a valid phone number.
Residential Address
*
Unit, Number, Street
City
*
Postal Code
*
Example: M4T 1Z6
Province
*
Please Select
ON
Other
How did you hear about this program?
*
Please Select
ACCESS staff
ACCESS client
Friend
Online (social media/website etc.)
Community agency (please note source below)
Other (please specify below)
Community Agency/Other (please specify referral source here)
What is your status in Canada?
*
Citizen
Permanent Resident
Convention Refugee/Protected Person
Other (please note in the section below)
If you selected other above, please fill in this section
What is your country of origin?
*
Country of Origin
How long have you been in Canada?
*
Under 1 year
1-5 years
6-10 years
More than 10 years
Born here
Gender
*
Please Select
Male
Female
Non-Binary
Prefer not to say
Which race category/categories best describes you?
*
Aboriginal/Indigenous
Black-(African, Afro-Caribbean, African-Canadian descent)
East Asian (Chinese, Korean, Japanese, Taiwanese descent)
Latino-(Latin American, Hispanic descent)
Middle Eastern-(Arab, Persian, West Asian descent, e.g. Afghan, Egyptian, Iranian, etc.)
Multiracial/ethnic
South Asian-(South Asian descent, e.g. Indian, Pakistani, Sri Lankan, Bangladesh, Indo-Caribbean, etc.)
Southeast Asian-(Filipino, Vietnamese, Cambodian, Thai, other Southeast Asian descent)
White (Caucasian)-(North American, European descent)
Another race category
Prefer not to say
If you selected another race category above, please specify it here.
Marital status:
Single
Married
Divorced
Widowed
Number of dependents (children):
0
1-5
6-10
More than 10
Annual Household Income (for you and your spouse/partner):
0-$10,000
$11,000-$20,000
$21,000-$30,000
$31,000-$40,000
$41,000-$50,000
$51,000-$60,000
$61,000-$70,000
$71,000-$80,000
$81,000-$90,000
$91,000-$100,000
Over $100,000
Level of Education
*
No formal education
Primary
Secondary
College or undergraduate
Post graduate
Employment status
*
Full time
Part time
Self-employed
Not employed
Student
Business Ideas and Experience
Business name and short description of product or service:
Business website/social media links:
Business links
Category of business:
Ex. Beauty, food, hospitality, etc.
I completed a business training with ACCESS or another organization:
*
Yes
No
I have a written business plan, but have not launched yet:
*
Yes
No
I have launched my business within the last 12 months without a business plan:
*
Yes
No
I have launched my business within the last 12 months with a business plan:
*
Yes
No
I have not yet launched, but I am ready to do so:
*
Yes
No
My business is formally registered:
*
Yes
No
If yes, what type of registration:
Sole proprietor
Partnership
Incorporated
I need one-on-one business coaching/mentorship:
*
Yes
No
If you answered yes to the above, please provide the area(s) you need coaching:
I need funding for my business in 3 to 12 months:
*
Yes
No
I plan to launch or have launched without external funding:
*
Yes
No
For the business coach/mentor, I prefer: (We will make every effort to meet your preferred choice, but may be limited based on available coaches).
*
Female
Male
No preference
My business topics of interest are as follows based on curriculum:
Program Attendance and Participation
To get the most out of the program, we strongly encourage commitment and attendance.
What may affect your ability to attend and complete the program? e.g. employment, school, childcare, the time of sessions, etc.
*
Are you committed and able to attend the program sessions?
*
Yes
No
Do you have access to a computer and reliable internet?
*
Yes
No
Media Consent and Release
As part of the program, we often do feature stories and profile our clients and their businesses. We would like your consent to share any content of those stories.
Do you authorize ACCESS Community Capital Fund to use your images or video footage, in whole or in part, individually or in conjunction with other images and video footage, to be displayed on its website and other official channels, and to be used for media purposes including promotional presentations and marketing campaigns? You agree to waive rights to privacy and compensation, which you may have in connection with such use of your name and likeness, including rights to written copy that may be created in connection with video production, editing and promotion therewith.
*
I agree
I do not agree
Today's Date
*
-
Month
-
Day
Year
Today's Date
Signature
*
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