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