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Partnership Application Form
Thank you for your interest in becoming a partner with Black Girl Health. Click the start button below to complete your application.
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1
May I have your name please?
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First Name
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2
Hello {fullname}! What is the name of your business?
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3
And your business address?
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Street Address
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State / Province
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Niue
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Northern Mariana
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Panama
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Poland
Portugal
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Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
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Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
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Serbia
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Somalia
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South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
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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
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
United States
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
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
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4
How can we contact you via email?
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example@example.com
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5
And by phone?
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Area Code
Phone Number
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6
Please select your business category.
*
This field is required.
1000 Arts, crafts, and collectibles.
1001 Baby.
1002 Beauty and fragrances.
1003 Books and magazines.
1004 Business to business.
1005 Clothing, accessories, and shoes.
1006 Computers, accessories, and services.
1007 Education.
1008 Electronics and telecom.
1009 Entertainment and media.
1010 Financial services and products.
1011 Food retail and service.
1012 Gifts and flowers.
1013 Government.
1014 Health and personal care.
1015 Home and garden.
1016 Nonprofit.
1017 Pets and animals.
1018 Religion and spirituality
1019 Retail (not elsewhere classified).
1020 Services - other.
1021 Sports and outdoors.
1022 Toys and hobbies.
1023 Travel.
1024 Vehicle sales.
1025 Vehicle service and accessories.
1000 Arts, crafts, and collectibles.
1001 Baby.
1002 Beauty and fragrances.
1003 Books and magazines.
1004 Business to business.
1005 Clothing, accessories, and shoes.
1006 Computers, accessories, and services.
1007 Education.
1008 Electronics and telecom.
1009 Entertainment and media.
1010 Financial services and products.
1011 Food retail and service.
1012 Gifts and flowers.
1013 Government.
1014 Health and personal care.
1015 Home and garden.
1016 Nonprofit.
1017 Pets and animals.
1018 Religion and spirituality
1019 Retail (not elsewhere classified).
1020 Services - other.
1021 Sports and outdoors.
1022 Toys and hobbies.
1023 Travel.
1024 Vehicle sales.
1025 Vehicle service and accessories.
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7
What is the mission of your organization and the services you provide?
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8
What does your organization need to be successful in reaching your mission and/ or maximizing your services?
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9
How do you think a partnership with BGH will help your organization?
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