ONLINE APPLICATION & PLEDGE FORM

Company Name (Required)

Primary Contact Name (Required)

Field label

Title

Address (Required)

Address Line 2

City

State/Province/Region

Phone (Required)

Email (Required)

Secondary Contact

Last Name

Fax

Secondary Title

Secondary Contact: Phone

Secondary Contact: Email

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*Both Primary and Secondary Contacts will receive the monthly WBEC ORV newsletter.

Who should be listed in the online WBENCLink database accessed by WBEC ORV Region WBE's?

Preferred WBENCLink Username (Required)

Preferred WBENCLink Password (Required)

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Online Information

Website Address

May WBEC ORV link your site?

Yes

No

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Contact For Website Information and Logo Usage

Name

First Name

Last Name

Phone Number

Email

Will you link WBEC ORV to your supplier information page on your website?

Yes

No

Select any WBENC affiliate organization of which you are currently a member

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Other Information

Do you currently have a supplier diversity program for women-owned business? (Required)

Yes

No

Can you provide in-kind support to WBEC ORV? (Required)

Yes

No

Industry

Products Produced

Products Purchased

Description of Service Provided

Dues Structure: Annual WBEC ORV Dues (Required)

$2,500 Corporate

$1,750 Non-Profit, Government

Consent (Required)

I understand and agree to the following:

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I UNDERSTAND THAT THIS APPLICATION IS CONSIDERED A COMMITMENT AND THAT MY CORPORATION WILL START RECEIVING MEMBERSHIP BENEFITS ACCORDING TO THE DATE MY APPLICATION IS RECEIVED.

Authorizing Signature (Required)

Company

Date (Required)

ONLINE APPLICATION & PLEDGE FORM

CORPORATE MEMBERSHIP APPLICATION

Online Application & Pledge

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