EIR Request Form
The information on this form will help us connect you with an EIR. This information will be shared with the EIR that you are connected with, prior to meeting or speaking with him or her. As a client of the WBC the information you submit on this form is confidential and will only be shared with an EIR.
Client Name *
First and last name
Your answer
Primary Phone Number *
Your answer
Primary Email Address *
Your answer
Business Name *
Your answer
Business Website *
Please include website link. If you do not have a website please let us know.
Your answer
How long have you been in business? *
Please describe the nature of your business *
Your answer
Where is your business located? *
Your answer
Please explain your revenue model *
Your answer
Please describe a specific need, challenge or question that an entrepreneur with industry or area-specific expertise may be able to help you with. *
Please be as clear and concise as possible.
Your answer
Do you give the Women's Business Center at CEI permission to share relevant information about you and your business with the EIR that we connect you with, including information on this form? *
How did you hear about the EIR program? *
Today's Date *
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Signature *
Please enter your first and last name in the space below. *Note that we will consider this as an E-signature.
Your answer
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