Impact Toolbox Program Application

Section 1 – Personal Information

Name(Required)

First Last

Business Name(Required)

If you do not have a business name yet, please enter N/A.

Are you a current loan client of WeBC or the Vancity Unity program?(Required)

Yes // Oui

No // Non

Mailing Address(Required)

Street Address Address Line 2 City Province Postal Code

Contact Telephone(Required)

Primary E-mail(Required)

For statistical purposes, please indicate if you are:(Required)

Immigrant or refugee

Indigenous

Person with disability

LGTBQIA2S+

A visible minority

None of the Above

Prefer not to say

Please indicate which group you identify with:(Required)

If you are an immigrant, please indicate how many years you have been a permanent resident of Canada.(Required)

Would you like to receive:

Please note that you may update your subscription preferences at any time through the WeBC website.

eNews – 9x per year publication filled with information and announcements of events relevant to women entrepreneurs and small business owners.

eBlasts – targeted emails with information on upcoming events of interest to entrepreneurs and small business owners in your area. Frequency of these emails varies throughout the year.

Section 2 – Eligibility Information

Please indicate your birth date(Required)

All participants must be at least 19 years of age.

When did you start your business?(Required)

If you have not started your business yet please enter the date you hope to start it.

Indicate which phase your business is currently in:(Required)

Pre Start-up – I have not started my business yet

Start-up – In business less than two years

Growth Stage – In business two years or more

From what background are you transitioning into self-employment/business ownership?(Required)

If other, please explain

What is the highest level of formal education you have completed?(Required)

Section 3 – Program Information

Business Industry(Required)

Business Sector(Required)

Please provide a description of your business:(Required)

(max 255 characters, or approximately 50 words)

What problem or need have you identified in your community that you would like to address?(Required)

Why is addressing this problem important?(Required)

What preliminary ideas do you have for addressing the problem(s) you have identified?(Required)

How did you hear about this Program?(Required)

Section 4 – Terms and Conditions of Mentee Agreement

The purpose of this Mentee Agreement is to outline how WeBC and the mentee will conduct themselves and to ensure that all parties’ privacy is protected. Please review both the Collection & Use of Information and Acknowledgement & Release below and agree to their contents by checking each box. // L’objectif de cet Accord de mentorat est de décrire la manière dont WeBC et la mentorée se comporteront et de garantir la protection de la vie privée de toutes les parties. Veuillez prendre connaissance de la Collecte et de l’Utilisation des renseignements ainsi que de la Reconnaissance et de la Décharge ci-dessous et en accepter le contenu en cochant chaque case.

WeBC Collection and Use of Information

I have answered all questions on this form and certify that all information I have provided is complete and accurate.

I understand WeBC, receives funding for this program from Innovation, Science and Economic Development Canada (ISED).

I understand that information I have provided on this form or that has been collected about me during my participation in this program will be available to WeBC.

I understand that ISED is responsible for fulfilling reporting obligations; however, no personally identifiable information about me will be exchanged with the federal government to fulfill this requirement.

I consent to being contacted by ISED (or its agent) at intervals and up to 12 months after completion of my participation in this program for the purpose of program evaluation.

Collection and Use of Information

All information is collected pursuant to section 26(c) of the Freedom of Information and Protection of Privacy Act. The information provided will be used for administrative and evaluation purposes of this program. If you have any questions about the use of this information, contact the Director, Programs & Partnerships (250) 868-3454.

WeBC Collection and Use of InformationCollecte et Utilisation des renseignements par WeBC

J’ai répondu à toutes les questions de ce formulaire et je certifie que tous les renseignements que j’ai fournis sont complets et exacts.

Je comprends que WeBC reçoit des fonds pour ce programme de la part de Innovation, Sciences et Développement économique Canada (ISDE).

Je comprends que les renseignements que j’ai fournis dans ce formulaire ou qui ont été collectés à mon sujet pendant ma participation à ce programme seront mis à la disposition de WeBC.

Je comprends que ISDE est responsable du respect des obligations en matière de rapports; toutefois, aucun renseignement permettant de m’identifier personnellement ne sera échangé avec le gouvernement fédéral pour satisfaire à cette exigence.

Je consens à ce que ISDE (ou son agent) communique avec moi à intervalles réguliers et jusqu’à 12 mois après la fin de ma participation à ce programme aux fins de l’évaluation du programme.

Collecte et Utilisation des renseignements Tous les renseignements sont recueillis conformément à l’article 26 (c) de la Loi sur l’accès à l’information et la protection de la vie privée. Les renseignements fournis seront utilisés à des fins administratives et d’évaluation de ce programme. Si vous avez des questions sur l’utilisation de ces renseignements, veuillez communiquer avec le directeur des programmes et des partenariats en composant le 250 868-3454.

Collection & Use of Information(Required)

I have read and agree with the terms and conditions of the Collection and Use of Information as outlined above

WeBC Acknowledgement & Release

I acknowledge that, if I am matched with a mentor, my mentor is a source of experience and knowledge that I can draw from. I understand that my mentor does not provide “professional financial or legal advice,” but rather offers support and encouragement.

I hereby release my mentor from responsibility should I choose to rely on the information and advice provided to me by my mentor on behalf of WeBC.

Reconnaissance et Décharge de WeBC

Je reconnais que, si je suis jumelée à une mentore, celle-ci représente une source d’expérience et de connaissances dont je peux tirer parti. Je comprends que ma mentore ne fournit pas de « conseils financiers ou juridiques professionnels », mais qu’elle m’offre plutôt son soutien et ses encouragements.

Par la présente, je dégage ma mentore de toute responsabilité si je choisis de m’appuyer sur les informations et les conseils qui me sont fournis par ma mentore au nom de WeBC.

Acknowledgement & Release(Required)

I have read, understand and agree to the terms of the Acknowledgement & Release.

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