One-to-One Mentoring Program Application

Section 1 – Personal Information

Name(Required)

First Last

Business Name(Required)

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

Yes

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)

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)

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

Early 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 attained(Required)

On a scale of 1 to 4, with 1 being low and 4 being high, how would you rate your confidence level in managing all the aspects of your business and the business challenges you are facing?(Required)

What are the top three challenges that you face in developing your business?(Required)

Please select only THREE. To select multiple options, hold down the CTRL key and click.

If other, please explain

Section 3 – Program Information

The following information about your business will assist us in placing you in the appropriate mentoring format – group or one-to-one.

Business Industry(Required)

Business Sector(Required)

Please provide a description of your business:(Required)

(max 255 characters, or approximately 50 words)

Are you operating your business full time or part time?(Required)

Full Time

Part Time

How many hours a week do you typically spend working in your business(Required)

What are your average gross monthly sales?(Required)

Please provide us with the top three business goals you wish to achieve.(Required)

Which benefits do you hope to receive from participating in this program? (please choose 2)(Required)

Please select only TWO. To select multiple options, hold down the CTRL key and click.

If other, please explain

The flexibility of your schedule helps us to serve you better. When are you available to meet with your Mentor (approx 2 – 3 hours)?(Required)

Select all that apply

Morning

Afternoon

Evening

Weekend

How did you hear about our Mentoring Program?(Required)

Section 4 – Suggest a Mentor (optional)

Please indicate if there is someone in your community who you would like WeBC to approach on your behalf to become your mentor.

Name

First Last

Business

Telephone

Please use this space to provide us with any additional comments

(max 500 characters, or approximately 100 words)

Section 5 – 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.

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 Pacific Economic Development Canada (PacifiCan).

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 PacifiCan 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 PacifiCan (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.

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.

Acknowledgement & Release(Required)

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

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Section 1 – Personal Information

Section 2 – Eligibility Information

Section 3 – Program Information

Section 4 – Suggest a Mentor (optional)

Section 5 – Terms and Conditions of Mentee Agreement

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