Corporate Membership Pledge Form

2018CORPORATE MEMBERSHIP PLEDGE FORM

Application must be completed in full for processing.

Company Information:

Company Name: ______

Primary Contact Name:______Title: ______

Address: ______City: ______State:_____Zip:______

Phone: ______Fax: ______E-Mail: ______

Secondary Contact Name: ______Title: ______

Phone: ______Fax: ______E-Mail: ______

*Both Primary and Secondary Contacts will receive the monthly e-President’s Report

Who should be listed in the online WBENCLink database accessed by all WBEs?

(Please circle) Primary Contact Secondary Contact Other

If other, please complete the following:

Name:______Title: ______

Address: ______City: ______State:_____Zip:______

Phone: ______Fax: ______E-Mail: ______

Member Profile and Online Information:

Website Address: ______Supplier Diversity Website Address: ______

May we feature public information from your website to describe your company on our websites? Yes____No____

May WBENC Hyperlink to your site and social media platforms?

2018 Membership ApplicationRevised: 08/31/2017

InstagramYes____ No____@______

Twitter: Yes____No____

2018 Membership ApplicationRevised: 08/31/2017

LinkedIn: Yes____No____Facebook: Yes____No____Website____

2018 Membership ApplicationRevised: 08/31/2017

Contact for website information and logo usage: Name: ______

Phone: ______E-mail: ______

Will you link your supplier information page on your website to wbenc.org?

Yes ______No ______

WBENC Affiliations:

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

2018 Membership ApplicationRevised: 08/31/2017

Astra Women’s Business Alliance

Center for Women & Enterprise

Greater Women’s Business Council

Ohio River Valley Women’s Business Council

Women Presidents’ Educational Organization/DC

Women Presidents’ Educational Organization/NY

Women’s Business Council – Southwest

Women’s Business Enterprise Council-South

Women’s BusinessDevelopmentCenter – Chicago

Women’s Business Development Council – Florida

Women’s Business Enterprise Council PA-DE-sNJ

Women’s Business Enterprise Alliance

Women’s Business Enterprise Council – Great Lakes

Women’s Business Enterprise Council-West

2018 Membership ApplicationRevised: 08/31/2017

Membership Form Continued

Other Information:

Do you currently have a supplier diversity program for women-owned business? Yes _____ No____

If you answer “No,” what is your planned implementation schedule? ______

If you answered “Yes,” do you…

…. Require third-party certification?Yes _____ No ______

…..Accept WBENC certification? Yes _____ No ______

…..Accept other certifications for WBEs?Yes _____ No ______

Can you provide in-kind support to WBENC? Yes ______No _____

If yes, please describe______

______

How did you hear about WBENC?______

Industry:Products/Services Produced or Provided:

Description of Services Provided:

Products/Services Purchased:

Dues Structure:

Annual RevenuesWBENC Dues

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: ______

*Company’s Annual Revenues (most recent reported year, not a range): Revenues ______Year______

WBENC Annual Dues (Amount): ______(Dues are pro-rated by quarter to the end of the year.)

*Please Note: Signature and Company’s Annual Revenue are required for processing your application.

 Charge to my: 

Credit Card No: ______Exp Date: _ / __ /_____

Name as it appears on the Card: ______

Signature Authorizing Charge: ______

 Please invoice my corporationPurchase Order Number (if applicable)______

Billing Address: ______City: ______State:_____Zip:______

Return form via email to or . If you have any questions, please call Mia Delano, Sr. Director of Development, 202-872-5515 xt.8024.

Thank you for joining WBENC!!

2018 Membership ApplicationRevised: 08/31/2017