Member Application

    
        















        





        
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Complete the form below to receive free WBCUtah services and/or to sign up for the free Utah Women-Owned Business Directory.
The Utah Women-Owned Business Directory promotes Utah businesses that are woman owner/operated. This means that a woman owns, in part or fully, a legally registered for-profit business and controls the following:

Mission, vision & strategy
Short & long-term organizational decisions
Products or services, including product development
Pricing
Paying payroll (if she has W2 employees)
Operational processes and technology
Business assets and liabilities

 
 ASTERISK * QUESTIONS MUST BE ANSWERED 
(there are options for unknown/unstated)
 
*WE REVIEW EACH AND EVERY LISTING BEFORE APPROVAL. 
PLEASE ALLOW AT LEAST 24 HOURS BEFORE CHECKING THE DIRECTORY FOR YOUR LISTING. 

        
        
            
                Business Information
            
            
                
                    
                                Company Name:
            *

                        
                    
                
                
                    
                                Leave Blank:

                        
                    
                
                    
                        
                                    Phone:
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                                    Website:

                            
                        
                    
                                    
                        
                                    Email:
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                                    Business Description (200 char max):

                            
                        
                    
                                    
                        
                                    Directory Category:
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                                Employees:

                        
                            
                                Full-time
                                
                            
                            
                                Part-time
                                
                            
                            
                        
                    
                                    
                        
                                    Business Keywords (enter a space between words):

                            
                        
                    
                                    
                        
                                    Comments / Questions:

                            
                        
                    
                                            
                                
                                            County:
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                                            Do you want to be listed on our public Women-Owned Business Directory?:
            *

                                    
                                
                            
                            
                                
                                    
                                            In order to meet the many needs of business owners and entrepreneurs, we must carefully review and evaluate the effectiveness of our program to our supporters, stakeholders and funding sources. Information is for secure recordkeeping and required for federal reporting purposes only. Thank you for your assistance!:

                                
                            
                            
                                
                                    
                                            Race (mark all that apply):

                                
                            
                            
                                
                                    
                                            Black or African American:

                                
                            
                            
                                
                                    
                                            American Indian or Alaska Native:

                                
                            
                            
                                
                                    
                                            Asian:

                                
                            
                            
                                
                                    
                                            White:

                                
                            
                            
                                
                                    
                                            Native Hawaiian or Other Pacific Islander:

                                
                            
                            
                                
                                    
                                            Race - Unknown/Not Stated:

                                
                            
                            
                                
                                            Ethnicity:
            *

                                    
                                
                            
                            
                                
                                            Gender:
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                                            Do you consider yourself a person with a disability?:
            *

                                    
                                
                            
                            
                                
                                            Military Status:
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                                            Date of Birth:
            *

                                    
                                    Select
                                    M/d/yyyy
                                
                            
                            
                                
                                            Marital Status:

                                    
                                
                            
                            
                                
                                            Are you the primary source of income for your household:

                                    
                                
                            
                            
                                
                                            # in Household:

                                    
                                
                            
                            
                                
                                            Highest level of education completed?:

                                    
                                
                            
                            
                                
                                            Employment Status:

                                    
                                
                            
                            
                                
                                            Annual household Income:
            *

                                    
                                
                            
                            
                                
                                    
                                            What prompted you to contact us? (Referred by):

                                
                            
                            
                                
                                    
                                            SBA:

                                
                            
                            
                                
                                    
                                            Bank:

                                
                            
                            
                                
                                    
                                            Business Owner:

                                
                            
                            
                                
                                    
                                            Television/Radio:

                                
                            
                            
                                
                                    
                                            Magazines and Newspapers:

                                
                            
                            
                                
                                    
                                            Chamber of Commerce:

                                
                            
                            
                                
                                    
                                            Internet:

                                
                            
                            
                                
                                            If Internet (please indicate website):

                                    
                                
                            
                            
                                
                                    
                                            Other Client:

                                
                            
                            
                                
                                    
                                            Educational Institution:

                                
                            
                            
                                
                                    
                                            Word of Mouth:

                                
                            
                            
                                
                                    
                                            Local Economic Development Official:

                                
                            
                            
                                
                                    
                                            SBA Website:

                                
                            
                            
                                
                                    
                                            Small Business Development Center:

                                
                            
                            
                                
                                    
                                            US Export Assistance Center:

                                
                            
                            
                                
                                    
                                            SCORE Chapter:

                                
                            
                            
                                
                                    
                                            Women's Business Center:

                                
                            
                            
                                
                                    
                                            VBOC:

                                
                            
                            
                                
                                    
                                            Boots to Business:

                                
                            
                            
                                
                                    
                                            Referred by - Other:

                                
                            
                            
                                
                                            If Other (please specify):

                                    
                                
                            
                            
                                
                                    
                                            Referred by - Unknown/Not Stated:

                                
                            
                            
                                
                                    
                                            Business Information:

                                
                            
                            
                                
                                            Currently in Business?:
            *

                                    
                                
                            
                            
                                
                                            Legal Entity of Business:

                                    
                                
                            
                            
                                
                                            If Other Legal Entity (please specify):

                                    
                                
                            
                            
                                
                                            Business Ownership Percent Female:
            *

                                    
                                
                            
                            
                                
                                            Business Ownership Percent Male:
            *

                                    
                                
                            
                            
                                
                                            Home-Based Business?:
            *

                                    
                                
                            
                            
                                
                                            Conduct Business Online?:
            *

                                    
                                
                            
                            
                                
                                            Gross Revenues/Sales:

                                    
                                
                            
                            
                                
                                            Profits/Losses:

                                    
                                
                            
                            
                                
                                            No. of Government Contracts or Subcontracts Received:

                                    
                                
                            
                            
                                
                                            Dollar Value of Government Contracts Subcontracts Received $:

                                    
                                
                            
                            
                                
                                    
                                            Exporting:

                                
                            
                            
                                
                                            Exporting?:

                                    
                                
                            
                            
                                
                                            If exporting, to which countries?:

                                    
                                
                            
                            
                                
                                            No. of employees engaged in exporting?:

                                    
                                
                            
                            
                                
                                            Amount of Gross Revenues/Sales related to exporting $:

                                    
                                
                            
                            
                                
                                    
                                            SBA Lending & Assistance (mark all that applyl):

                                
                            
                            
                                
                                            SBA Loan Amount $:

                                    
                                
                            
                            
                                
                                            Number of SBA Loans:

                                    
                                
                            
                            
                                
                                    
                                            Export Express:

                                
                            
                            
                                
                                    
                                            Export Working Capital Loan:

                                
                            
                            
                                
                                    
                                            Community Advantage:

                                
                            
                            
                                
                                    
                                            SBIR:

                                
                            
                            
                                
                                    
                                            Payroll Protection Program (PPP):

                                
                            
                            
                                
                                    
                                            Economic Impact Disaster Loan (EIDL):

                                
                            
                            
                                
                                    
                                            Other SBA Disaster Loan for COVID-19:

                                
                            
                            
                                
                                    
                                            Other (SBIC 7(a), 504, etc.):

                                
                            
                            
                                
                                            If Other Financial Assistance, please specify:

                                    
                                
                            
                            
                                
                                            Non-SBA Loan Amount $:

                                    
                                
                            
                            
                                
                                            Number of Non-SBA Loans:

                                    
                                
                            
                            
                                
                                            Amount of Equity Capital Received $:

                                    
                                
                            
                            
                                
                                    
                                            Micro Loan:

                                
                            
                            
                                
                                            Number of transactions:

                                    
                                
                            
                            
                                
                                    
                                            State/Local COVID-19 Loans or Grants:

                                
                            
                            
                                
                                    
                                            Certifications:

                                
                            
                            
                                
                                            8(a) Certified?:

                                    
                                
                            
                            
                                
                                    
                                            8(a):

                                
                            
                            
                                
                                    
                                            HUBZones:

                                
                            
                            
                                
                                    
                                            Woman-Owned Small Business:

                                
                            
                            
                                
                                    
                                            Other Certification:

                                
                            
                            
                                
                                            If Other Certification, please specify:

                                    
                                
                            
                            
                                
                                    
                                            REQUEST FOR ASSISTANCE:

                                
                            
                            
                                
                                            What is the nature of service you are seeking? (Choose primary category):
            *

                                    
                                
                            
                            
                                
                                            If Other, describe specific assistance requested:

                                    
                                
                            
                            
                                
                                            Preferred Language:
            *

                                    
                                
                            
                            
                                
                                    
                                            I request business counseling and/or training service from the Women's Business Center of Utah, funded in part by the Small Business Administration (SBA). I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA services. I permit SBA or its agent the use of my name and address for SBA surveys and information mailings regarding SBA products and services:

                                
                            
                            
                                
                                            Do you agree with the statement above?:
            *

                                    
                                
                            
                            
                                
                                    
                                            NON-DISCLOSURE AGREEMENT:   I understand that any information disclosed will be held in strict confidence. (SBA will not provide your personal information to commercial entities.) I authorize SBA to furnish relevant information to the assigned management counselor(s) which may include contractors of the WBCUtah.:

                                
                            
                            
                                
                                    
                                            I further understand that the counselor(s) agrees not to: 1) recommend goods or services from sources in which he/she has an interest, and 2) accept fees or commissions developing from this counseling relationship. In consideration of the counselor(s) furnishing management or technical assistance, I waive all claims against SBA personnel, and that of its Resource Partners and host organizations, arising from this assistance.:

                                
                            
                            
                                
                                    
                                            USE OF INFORMATION:

                                
                            
                            
                                
                                    
                                            The information in this form is to be provided by individuals and business seeking technical assistance services from the Small Business Administration (SBA) or an SBA Resource Partner. The information is collected to help SBA's continuing improvement of business counseling programs, to ensure effective oversight and management of entrepreneurial development programs and grants, and to meet Congressional and Executive Branch reporting requirements. :

                                
                            
                            
                                
                                            Client Signature (by typing your name you agree to the statements above.): :
            *

                                    
                                
                            
                            
                                
                                            Client Signature Date:
            *

                                    
                                    Select
                                    M/d/yyyy
                                
                            
            
                
                    Physical Address
                    
                        
                                    Line 1:
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                            Line 2:
                            
                        
                    
                    
                        
                                    City:
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                                    State (Use 2 letters in all caps):
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                                    Postal Code:
            *

                            
                        
                    
                    
                        
                                    Country:
            *

                            
                            
                        
                    
                
                            
                    Mailing Address
                        
                            
                                
                                Same as physical address
                            
                        
                    
                        
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                            Line 2:
                            
                        
                    
                    
                        
                                    City:

                            
                        
                    
                    
                        
                                    State (Use 2 letters in all caps):

                            
                        
                    
                    
                        
                                    Postal Code:

                            
                        
                    
                    
                        
                                    Country:

                            
                            
                        
                    
                
                            
                            Social Networking:

                    
                            
                                LinkedIn
                                
                            
                            
                                Facebook
                                
                            
                            
                                Instagram
                                
                            
                    
                
        
            
                
                    Primary Contact Information
                
                
                    
                        
                                    First Name:
            *

                            
                        
                    
                    
                        
                                    Last Name:
            *

                            
                        
                    
                        
                            
                                        Title:

                                
                            
                        
                                            
                            
                                        Phone:

                                
                            
                        
                                            
                            
                                        Cell Phone:
            *

                                
                            
                        
                                                                
                            
                                        Email:
            *

                                
                            
                        
                                            
                            Contact Preference:
                            
                                
                                    
                                    Email
                                
                                
                                    
                                    Phone
                                
                            
                        
                                            
                            
                                        Login:
            *

                                
                            
                        
                        
                            
                                        Password:
            *

                                
                            
                        
                        
                            
                                
                            
                            
                        
                                            
                                    Social Networking:

                            
                                    
                                        LinkedIn
                                        
                                    
                                    
                                        Facebook
                                        
                                    
                                    
                                        Instagram
                                        
                                    
                            
                        
                                            
                            Address
                                
                                    
                                        
                                        Same as Member Address
                                    
                                
                            
                                
                                            Line 1:

                                    
                                
                            
                            
                                
                                    Line 2
                                    
                                
                            
                            
                                
                                            City:

                                    
                                
                            
                            
                                
                                            State (Use 2 letters in all caps):

                                    
                                
                            
                            
                                
                                            Postal Code:

                                    
                                
                            
                            
                                
                                            Country:

                                    
                                    
                                
                            
                        
                
            
        
            
                Membership Options
            
            
                    
                                Membership Package:
            *

                        
                                
                                    
                                    
                                        Northern Utah WBCUtah Client:
                                        
                                        

                                        Counties: Cache, Daggett, Duchesne, Box Elder, Davis, Juab, Morgan, Rich, Salt Lake, Summit, Tooele, Uintah, Utah, Wasatch and Weber.
                                    
                                
                                
                                    
                                    
                                        Southern Utah WBCUtah Client:
                                        
                                        

                                        Counties: Beaver, Carbon, Emery, Garfield, Grand, Iron, Kane, Millard, Piute, San Juan, Sanpete, Sevier, Washington and Wayne.
                                    
                                
                                                    
                    
                                                            
        
        
            
                
                    
                
            
        
        
            
                
                    Please scroll down to view the entire policy and then click Accept.

                    Any information disclosed will be held in strict confidence. (SBA will not provide your personal information to commercial entities.) By completing and electronically signing the profile, you will authorize SBA to furnish relevant information to the assigned management counselor(s).

 

The WBCUtah counselor(s) agrees not to: 1) recommend goods or services from sources in which he/she has an interest, and 2) accept fees or commissions developing from this counseling relationship. In consideration of the counselor(s) furnishing management or technical assistance, I waive all claims against SBA personnel, and that of its Resource Partners and host organizations, arising from this assistance.

 

Also, by signing the Non-Discloures Agreement, you will formally authorize the WBCUtah to use your name and image for promotional activities sponsored by the WBCUtah.
                    

                    

                    
                        
                        Decline
                    
                
            
            
                
                I have read and accept the privacy policy of Women's Business Center of Utah. I grant Women's Business Center of Utah permission to contact me regarding my account, news, updates, and offers.
            
            
                
                    Please read and accept the privacy policy before continuing.
                
            
        
        
            
                
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