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
City	State / Province
Postal / Zip Code	Country

Head of Procurement
Name: *

First Name Middle Name Last Name

Mailing Address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number: *
xxx-xxx-xxxx
Fax: *
xxx-xxx-xxxx
Council Representative (Main Contact):
Name: *

First Name Middle Name Last Name

Mailing Address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

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

Yes No
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? *

Yes No
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:

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

Signature *
Name *

First Name Last Name
Title *
Date *

Month Day Year
Date Date Picker Icon
Should be Empty:

Council Member Application

Head of Procurement

Council Representative (Main Contact):

Confidential Information

Authorization and Dues