Membership Application "*" indicates required fields CompanyThis field is for validation purposes and should be left unchanged.ORGANIZATION INFORMATIONCompany Name*Company URL* Primary Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Industry*Select OneAdvertising & MarketingAerospace & DefenseAutomotiveBiotech & PharmaceuiticalChemicalsConstruction, Engineering & Inudstrial ManufacturingConsumer ProductsEducationEnergyFinancial ServicesFood & Bev and AgricultureGovernmentHealthcareInsuranceNon-ProfitProfessional ServicesReal Estate & Facility ManagementRetailTechnology & ConnectivityTransportation & LogisticsTravel & HospitalityUtilitiesSecondary Industry*Select One or "Not Applicable"Not ApplicableAdvertising & MarketingAerospace & DefenseArts, Entertainment & RecreationAutomotiveBiotech & PharmaceuticalChemicalsConstruction, Engineering & Industrial ManufacturingConsumer ProductsEducationEngergyFinancial ServicesFood & Bev and AgricultureGovernmentHealthcareInsuranceNon-ProfitProfessional ServicesReal Estate & Facility ManagementRetailTechnology & ConnectivityTransportation & LogisticsTravel & HospitalityProducts/Services Sold to Customers*Products/Services Purchased from Suppliers*Reason for joining WBEC South*CONTACT INFORMATION(Both primary and secondary contacts will receive communications from WBEC South)Primary Contact Name*Title*Email* Phone*Secondary Contact NameTitle*Email* Phone*WBENCLink 2.0 Contact Name*Title*Email* Phone*SUPPLIER DIVERSITY INITIATIVESDo you currently have a supplier diversity program that includes women-owned businesses?* Yes No If Yes, do you:* Require 3rd Party Certification Accept WBENC Certification Accept other certifications for WBEs If No, what is your planned implementation schedule?*Will you provide a link to wbenc.org on your supplier website?* Yes No Indicate the WBENC Regional Partner Organizations you are currently a member of : Center for Women & Enterprise Greater Women's Business Council Women's Business Development Center Midwest Women's Business Council Southwest Women' Business Enterprise Center East Women' Business Enterprise Council South Women' Business Enterprise Council Metro NY WEConnect International Great Lakes Women's Business Council Women's Business Enterprise Council Ohio River Valley Women's Business Enterprise Council Florida Women's Business Enterprise Alliance Women' Business Enterprise Council - Pacific Women's Business Enterprise Council - West Women's Business Enterprise Council Greater DMV CORPORATE COMMITMENT WBEC Corporate Membership runs the calendar year, January 1 - December 31. WBEC will prorate new members for the quarter in which they join. Annual Dues Structure : CORPORATE $3,000.00 GOVERNMENT $1,500.00 UNIVERSITIES $1,500.00 NONPROFIT/OTHER $1,000.00 Organization's Reported Annual Revenue*Most recent year reported, not a range.Year*Agreement* I agree to the statement belowI understand that this application is a commitment to membership. My corporation will be invoiced upon date of acceptance and begin receiving membership benefits immediately.BILLING INFORMATIONDesired Membership Start Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Invoice my corporation Invoice my corporation Annual Dues to be Invoiced*Purchase Order (if applicable):Billing address is same as previously listed Primary address.* Yes No Call for Credit Card information Call for credit card information Phone number to call for credit card information*Billing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
