Apply to SELL NWA – Small Business E-commerce Local Learning

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Business Assistance Application

The information collected will be protected per the Winrock Privacy Statement’s Safeguarding commitment. The information collected will be used solely for the purpose of program administration and will be permanently deleted once it is no longer needed for that purpose.

Company Name*
Company Address
Street Address Address Line 2 City State ZIP Code
Is the company located in Benton County, Arkansas?
- Yes
- No
Is the company located in Washington County, Arkansas?
- Yes
- No
Company Owner Name
Company Owner Email Address
Contact Phone Number
Business Industry
Business Start Date?
MM slash DD slash YYYY
What is the legal entity of your business?
- Sole proprietorship
- S-Corporation
- Corporation
- LLC
- Partnership
- Other
Gender
- Female
- Male
- Other
- Prefer Not to Say
Does your business have a website?
- Yes
- No
Does your business have an e-commerce platform?
- Yes
- No
Is your business at least 51% owned, operated and controlled on a daily basis by one or more women?
- Yes
- No
If you answered yes to the question above, what percentage of your business is woman-owned?
Is your business at least 51% owned, operated and controlled on a daily basis by one or more (in combination) American citizens of the following ethnic minority classifications: African American, Asian American (includes West Asian Americans (India, etc.) and East Asian Americans (Japan, Korea, etc.), Hispanic American, Native American including Aleuts?
- Yes
- No
If you answered yes to question above (#?), please indicate the category or categories that pertain to you:
- African American
- Asian American
- Hispanic American
- Native American including Aleuts
Does the company owner consider himself or herself to be disabled?
- Yes
- No
Veteran Status:
- Non-veteran
- Veteran
- Service-disabled veteran
Is the company owner active duty or member of reserve/National Guard?
- Yes
- No
How many full-time employees does your company have?
How many part-time employees does your company have?
How many full-time employees do you project to have by year-end 2021?
How many part-time employees do you project to have by year-end 2021?
What was your company’s revenue for the last two years? Please specify by year.
What is your anticipated 2020 revenue?
What is your anticipated 2021 revenue?
What days and times is the company owner typically available for consultation and training?
How did you hear about the Small Business E-commerce Local Learning Project?
CAPTCHA

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