WBEC-East Council Member Application

Council Member Application

Please expect to receive a response within the next two weeks.
Company:*
Headquarters Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Council Representative (Main Contact):
Name:*

First NameMiddle NameLast Name
Title*
Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number:*
xxx-xxx-xxxx
Fax:
xxx-xxx-xxxx
Head of Procurement or Supplier Diversity (Secondary Contact)

Please Note: Please list a different point of contact here, other than yourself so we have a backup should we be unable to reach you regarding your membership status, etc.
Name:*

First NameMiddle NameLast Name
Title*
Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number:*
xxx-xxx-xxxx
Mobile Number*

Area CodePhone Number
Fax:
xxx-xxx-xxxx
Do you currently have a Supplier Diversity Program?*

YesNo
Main Company Website:*
Supplier Diversity Website/Link:
Referred by:
Business Description (SIC codes):
Commodities Purchased (Description and SIC/NAICS codes):
Services Purchased (Description and SIC/NAICS codes):
List the regions where you have facilities requiring Commodity or Service purchases:
Is your company affiliated with other WBENC Regional Partner Organizations?*

YesNo
If yes, which Councils?
Starting month of your fiscal year:*
Ending month of your fiscal year:*
Confidential Information

If published, only aggregate figures will be used, not individual company statistics.
Annual Corporate Sales:
$
Annual purchases with women owned business of PA, NJ, and DE:
$
Number of Employees
Numbers only
Authorization and Dues
We hereby support the Women's Business Enterprise Center and agree to enhance business opportunities for women business enterprises.

We understand that participation in the activities of WBEC-East is voluntary. We wish to provide the following (non-refundable) financial support:

$3,500	Membership Dues
Plus	Sponsorship Contribution (Ranging from $2,500 to $10,000) or Individual Event Sponsorship Cost

Total Amount for Council Dues
financial support you plan to provide to WBEC-East
Signature*
Name*

First NameLast Name
Title*
Date*

MonthDayYear
Date
Should be Empty:

Council Member Application

Council Representative (Main Contact):

Head of Procurement or Supplier Diversity (Secondary Contact)

Confidential Information

Authorization and Dues