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Application Form
Business Information
*
Indicates required field
Legal Business Name:
*
Business Name (if different from Legal Name):
*
Business Identification Number (from the Nova Scotia Registry of Joint Stocks):
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Business Incorporation Type:
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Does this business report to a head office outside of Nova Scotia?
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Yes
No
If Yes, what is the Parent company's name and location?
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Business Full Civic Address:
*
Business Full Mailing Address (if different than Civic address):
*
Website:
*
Contact Information
Contact Person:
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Contact Person's Title:
*
Phone Number:
*
Email Address:
*
Additional Information
Please describe your business, including an overview of the products or services you offer (less than 500 words):
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Annual Revenue (choose one):
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< $100K
$101K - $250K
$250K - $1M
> $1M
Total number of full-time equivalents (FTEs) in Cumberland Region:
*
Approximately what percentage of annual sales is reinvested into R&D (new or improved product, process, service, etc.) activities?
*
Approximately what percentage of your annual sales is outside of Nova Scotia?
*
How has COVID-19 affected your business? (revenue, layoffs, etc.) (less than 500 words):
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What is the biggest issue your company is facing which a virtual adviser can assist with? (less than 500 words)
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What impact would solving this issue have on your business? (i.e. increased revenue or exports, additional or retained employees, new or improved products, services, or processes, etc.) (less than 500 words):
*
Do you have the time and resources available to commit to the virtual adviser calls (4 to 6 calls, 30 to 40 minutes each, over 2 to 3 months), and the follow-up work required to work on the issue for the duration of the program?
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Yes
No
Will you commit to providing feedback and input, including a final survey once the project is complete?
*
Yes
No
On behalf of the business identified above, I hereby submit the application for the Virtual Adviser Program. I certify that I am an authorized officer of the business and that the information provided in this application and its attachments is true and correct to the best of my knowledge and belief. I agree to comply with the program requirements, including reporting requirements.
I acknowledge and agree to allow the Cumberland Business Connector, BoomersPlus or a designate to make any inquiries of such persons, firms, corporations, and federal and provincial government agencies/departments required to collect and to share information with them, including personal information as defined in the Freedom of Information and Protection of Privacy Act, as the Cumberland Business Connector deems necessary, in order to reach a decision on this application; to administer and monitor the implementation of the Virtual Adviser program; and to evaluate the results of this program after project completion. I hereby waive confidentiality of such information and agree that its collection and disclosure will not be the basis of any liability, claim or order against the Cumberland Business Connector.
By signing below, you consent to the Cumberland Business Connector releasing your contact and application information to BoomersPlus or any third-party service providers retained for the purposes of delivering and evaluating the program. This consent is valid whether your application is successful or not. You agree to being contacted by BoomersPlus or any such third-party service providers and will cooperate with them in the collection of information required for the delivery and the evaluation of the program. You further agree to release the Cumberland Business Connector, BoomersPlus and their respective staff, Advisers, and third party service providers from any claims, causes of action, suits, actions and liabilities of every nature and kind whatsoever arising from, as a result of or in any way related to the aforementioned authorized release of contact information and subsequent collection and use of information. If you do not consent to the disclosure of your contact information, you cannot participate in the Virtual Adviser Program.
Should the business be a successful applicant, on behalf of the business, I hereby give the Cumberland Business Connector permission to release the name of the business in any form and through any media for purposes of marketing this program.
*
Yes
No
Initials
*
I authorize, certify, and agree to all the terms above. Authorized Officer Name
*
Job Title
*
Submit
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