Women@Work Network LLC

NOTE: Please answer all questions within this questionnaire - any documents such as company profiles must be cut and pasted into this application.

Client References: Names, phone numbers and email addresses of three clients Women@Work can contact.
Category:
Company Information
Company Name:
Address Line 1:
Address Line 2:
City:
State:
Zip:
Main Phone Number:
Website Address (be sure to include the http://):
Type of Service:
Year Established:
Representative List of Corporate Clients (if applicable):
Description of Services Targeted to Women (500 word limit):
Description of Services Available Via Phone and Email:
Description of Fee Structure (Note: The more fee information that you provide, the more likely that you will generate "qualified" inquiries.):
Client Reference 1:
Client Reference 2:
Client Reference 3:
NOTE: If you have written letters of recommendation from these clients, please fax them to 203-762-7277
Key Contact Information
Name:
Title:
Direct Phone Number:
Email Address:
Professional Designations:
Professional Affiliations:
Community Involvement:
Special Professional Recognition (e.g., awards received):
Media Coverage Received:
Professional Bio:

Once we review all your information, you will receive confirmation of your Women to Women Directory Listing and an invoice for $150.00 to cover the 3-month introductory period.