Determined Entrepreneur Program * First Name Last Name How did you hear about this WSBA program? * Social media An organization other than WSBA Word of mouth Internet search I was referred by someone None of these If someone referred you, put their name here, if not just leave it blank Phone (###) ### #### Email * Business Name * Business Address Address Line 2 City * State * Zip Code * Business Email Business Phone (###) ### #### Legal structure of your business * Sole Proprietorship Partnership Corporation S Corporation Limited Liability Company (LLC) I'm not sure Business Website Link If you don't have one, just type, "no website" Current Revenues As of application date Briefly describe your business What are your top three biggest business challenges? What are the three outcomes you would like to achieve through this program? * Do you have the following? * Marketing Plan Business Plan Both Marketing and Business Plan In process What percentage of your business is woman-owned? Race * Caucasian African American/Black Hispanic/Latino Asian Middle Eastern Pacific Islander Native American/Alaskan Other Age 21-29 30-39 40-49 50-59 60+ Veteran Status I am a veteran of the armed services My spouse/partner is a member of the armed services My spouse/partner and I are both a member of the armed services I am not a veteran of the armed services Household Income 0 - $9,999 $10,000 - $24,000 $25,000 - $49,000 $50,000 - $74,000 $75,000 - $99,999 $100,000 - $149,000 $150,000+ I understand the program fee is $3,000. I would like to be considered for the following payment terms: Full payment Partial WSBA Scholarship: based on verified financial need. Please email your previous year's taxes to gloria@wsbaohio.org upon completion of this application Accelerate Columbus Scholarship: Must work in the city of Columbus to be considered Terms for the Determined Entrepreneur Program * I understand that by signing below, I am agreeing to the terms of the Determined Entrepreneur Program facilitated by the Women’s Small Business Accelerator, Inc. I also understand that the WSBA does not perform any tasks on behalf of or for program attendees. As a program attendee I take full responsibility and liability for the implementation of any feedback. Completion and submission of the application is merely a request for entrance into the Determined Entrepreneur Program, and not a guarantee of acceptance. • All participants will be required to sign a non-disclosure/confidentiality agreement. • All participants and volunteers will be required to give us permission to use their name, company name and a professional photo in a WSBA media release, marketing, and the WSBA website for the purpose of promoting WSBA and its programs. However, no proprietary information will be used. By signing this application, you are giving the WSBA permission to use the information described above. I agree Thank you!
