MinnesotaSmallBusinessWeek
Women in Business Champion
Nomination Form
Instructions:
This form must be completedbythe nomineeor bythe nominator. Thecompleted form must besubmitted with the nominationpackage asnotedin the awardguidelines.Answereach questionas fullyaspossible; if it is not applicable,state N/A.
1.LeadNomineeInformation:
a.Name:
b.Title:
c.Businessname:
d.Business address:
e.Business phonenumber:
f.Businessemail address:
2.Co-nominee(s)Information(Note:youmaynominate up to 3 additional co-nominees perbusiness.Eachco-nominee mustfill out the SBAForm 3300):
a.Name(s):
b.Title(s):
c.Emailaddress(es):
3.NominatorInformation (ifyouare nominatingyourself,write n/a):
a.Nominator name:
b.Title:
c.Address:
d.Phone number:
e.Emailaddress:
4.Providethe nominee(s)percentage of ownershiporstockowned in thesmall business (if it is not applicable,state N/A).
5.Howmany yearshas thenominee’s business beenoperational (minimum 3 years) (if it is not applicable,state N/A)?
6.Howmanyemployees does the businesscurrentlyhave (if it is not applicable,state N/A)?
7.Does the business have awebsite?Ifyes, list the URL:
8.To assess the financialperformance of thebusiness forthe last 3 calendaryears, fill out thechartbelow (if it is not applicable,state N/A).
FinancialSummaryYear / 2012 / 2013 / 2014
Number of Employees
Total Sales
NetProfit(Before Tax)
Total Assets
Total Liabilities
Net Worth
Answer each ofthe followingquestionsin 200words orless.
9.Provideabiographyfor thenominee(s):
10.Has the business receivedSBAassistance(e.g. SBA loan, SCORE counseling,SBDCassistance,WBCassistance contractingor Emerging LeaderInitiative)?Ifyes, pleaseexplain (include the amountanddate offinancialassistance received if applicable):
11.Describe any active support for legislative or regulatory action designed to help small businesses.
12.Has thenominee demonstrated efforts to increase business and financial opportunities for women?Ifyes, pleaseexplain.
13.Has the nominee provided legal, financial or managerial assistance to enhance women's business ownership? If yes, please explain.
14.Describe any voluntary efforts to strengthen the role of women business owners within the community.
15.Does the nominee advocate for the women-owned business community as a whole, not solely for individual personal advancement? If yes, please explain.
16.Provide any other accomplishments demonstrating effectiveness in improving the environment for the creation and expansion of businesses owned and operated by women.