One-to-One Mentee Application Form - Women's Enterprise Centre

Section 1 - Personal Information

Name*

First Last

Business Name*

Mailing Address*

Street Address Address Line 2 City Province Postal Code

Contact Telephone*

Primary E-mail*

For statistical purposes, please indicate if you are:*

Immigrant
Indigenous
Person with disability
Youth
None of the Above

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

Would you like to receive

Please note that you may update your subscription preferences at any time through the WEC 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*

All participants must be at least 19 years of age.

When did you start your business?*

Indicate which phase your business is currently in*

Pre Start-up – I haven’t launched my business yet. I am in the research, planning and business development stage.
Start-up – I am actively operating my business and generating revenue for less than two years.
Early Growth Stage – I have been in business for two or more years. My business is building momentum and I am anticipating expansion and/or increases in product/service demand.

From what background are you transitioning into self-employment/business ownership?*

If other, please explain

What is the highest level of formal education you have attained*

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*

1
2
3
4

What are the top three challenges that you face in developing your business?*

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*

Business Sector*

Please provide a description of your business:*

(max 255 characters, or approximately 50 words)

Are you operating your business full time or part time?*

Full Time
Part Time

How many hours a week do you typically spend working in your business*

What are your average gross monthly sales?*

Please provide us with the top three business goals you wish to achieve*

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

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)?*

Select all that apply

Morning
Afternoon
Evening
Weekend

How did you hear about our Mentoring Program?*

Section 4 – Suggest a Mentor (optional)

Please indicate if there is someone in your community who you would like Women’s Enterprise Centre 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 Women’s Enterprise Centre 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.

Women's Enterprise Centre 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 the Women's Enterprise Centre, receives funding for this program from Western Economic Diversification Canada.

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 Western Economic Diversification Canada.

I understand that Western Economic Diversification Canada 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 Western Economic Diversification Canada (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 Manager, Skills Development, Women's Enterprise Centre (250) 868-3454.

Collection & Use of Information*

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

Women's Enterprise Centre 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 Women's Enterprise Centre.

Acknowledgement & Release*

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

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