Membership Application

Membership privileges include:

Membership Classification
	Member - voting members and those who may serve on the Board of Directors must be: 51% or more Women owned business Independently owned and operated business Business and/or residence located in Suffolk County
	Associate Member: 51% or more Women owned business Independently owned and operated business Business and/or residence located in Nassau County
	Resource Member: Any organization that provides services to the membership; but who do not compete directly with member companies.

Your Membership Information
First Name:
Last Name:
Company / Agency Name:
Title / Designation:
Category:
Company Address:
City:
State:
Zip:
Phone:
Fax:
E-mail:
Web Address:
Principal Female Owner(s): (Not required for corporate or resource members)
Full Name:
Percentage Owned:
Full Name:
Percentage Owned:
*If business is not located in Suffolk County, a Suffolk County residential address is required for membership eligibility. This information will NOT be published.
Residential Address
Address:
City:
State:
Zip:
Products and Services: (Please provide a brief description of your company's products and services) :
Certification History (Please list any agency you have been certified by as a Woman Business Enterprise (WBE) or Disadvantage Business Enterprise (DBE):
The information in this application will be published in our directory and on our website. Do you wish to have this information published?
YES	NO
I agree that the information provided above is true to the best of my knowledge.