DEADLINE: January 17, 2012

Date of Application:

Women Business Owner(s):

Business Name:

Business address:

City: State: ZIP:

Phone: Fax: Cell/Pager:

Email: Website:

Qualification Questions

Month/Year business began:

Percent of business owned by one or more women:

Does the Applicant actively manage the business? Yes No

Number of employees (include applicant if applicable): Full Time Part Time

Date Fiscal Year Ends:

Sales or revenue history (use annual fiscal year numbers; do not include cents):

Last fiscal year $ Previous fiscal year $ 2 years previous $

Projected for this fiscal year Budget for next fiscal year

Is there anything the ATHENAPowerLink® Program should know about you or your business; i.e., do you have any litigation pending? Are there significant personal or business financial difficulties?

Have you applied for an ATHENAPowerLink® Advisory Panel before? Yes
No

If yes, when, and please describe why you did not receive one:

Business Questionnaire

1. Do you have a business plan? Yes No

If yes, attach business plan:

2A. Briefly describe your goals for the business over the next one year:

2B. Briefly describe your goals for the business over the next five years:

3. Do you have financial projections for the next one to two years? Yes
No

If yes, attach financial projections:

4. Does your business currently have a board of directors? Yes
No

If yes, attach complete list including areas of expertise for each:

5. Do you expect any significant change in business ownership or operation during the next 18 months? Yes
No

If yes, please describe.

6. Briefly describe your business' products.

7. Who are your three largest customers? Approximately what percentage of last year's sales do they represent? Approximately what is your average size sale overall?

8. Briefly describe your business' major strengths and major weaknesses.

9. Briefly describe your major competition and its/their strengths and weaknesses.

10. What are your primary tasks as president/owner? Which do you enjoy more: (a) running the business or (b) being in the industry?

11. What frustrates you most about running your business?

12. What is your highest business priority and how do you see an Advisory Panel being able to help you reach that priority?

13. Have you participated in a Small Business Administration Program such as SCORE or an SBDC? Yes
No

If so, please state when and describe how your business benefited.

14. What successful adviser/advisee relationships have you had while running this business? What good advice have they given you? How has this affected your business? Has it resulted in any lasting or permanent change?

The information contained in this application is provided for the purpose of obtaining an unpaid Advisory Panel through the ATHENAPowerLink® Program. I understand that you are relying on the information provided herein in deciding to grant an Advisory Panel, and therefore, I represent that the information provided is true and complete.

Signed: