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Your First Name*

Your Last Name*

Your Email*

Your Phone Number*

Your relationship to this business:

Resource Information

Business Name*

Business Website Address*

Business Street Address*

City*

State/Province*

Zip Code*

Please provide a reference that we can contact regarding this business?

What area of expertise would best describe this business?*

Auto Repair/Maintenance*

Household Management*

Financial Services*

Legal Services*

Mental Health*

Health and Wellness*

Other

Service Area

What area does this business serve?

States*

Cities*

Zip Code(s)*

Mileage Radius*

Are you willing to collaborate with TWC to offer free or discounted services?*

Please provide a description of your services in 3-5 sentences which could be used on TWC’s website and submit a logo in .jpg or .png format to resources@thewidowcollaborative.com

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(DISCONTINUED) Referrer's Phone Number

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(DISCONTINUED) If you offer multiple services, please list each service provided below

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(DISCONTINUED) How long have you been in business?*

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(DISCONTINUED) What is your area of expertise?*

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(DISCONTINUED) State(s)*

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(DISCONTINUED) Mileage Radius*

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(DISCONTINUED) If applicable, do you go to clients and/or do clients come to you?

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(DISCONTINUED) Can clients access services online (such as a website) and/or virtual (such as Zoom, Teams, etc.)

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Collaboration

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(DISCONTINUED) Are you willing to offer free or discounted services to widows in the TWC community? If so, please describe

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References

Please provide a reference who has knowledge of your business and/or service

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(DISCONTINUED) Name

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(DISCONTINUED) Phone

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Service Area

Collaboration

References

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