Application Form: International Business Mentoring Program If you are selected to participate in the Program, Canberra Business Chamber (CBC) will provide some of this information to panel mentors of the Program in advance of your meeting with the mentors. CBC treats all personal information provided by an individual in support of an application in accordance with the Commonwealth Privacy Act 1988. Business detailsBusiness Legal / Registered Name*Trading Names:*Australian Business Number (ABN):*State/Territory registered for ABN:ACTNSWVICNTWAQLDAustralian Company Number (ACN) if applicable:State registered for ACN:ACTNSWVICNTWAQLDDate of incorporation or formation of company:Contact personName:*Position:*Office phone number:*Mobile phone number:Email address:* Mailing address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Target groupsPlease indicate if the business owners belong to one or more of the following groups: People from Culturally and Linguistically diverse backgrounds Women Business descriptionWhich industry sectors does your organisation belong to?* Information Communication Technology Defence Cyber Security Renewables Technology Space and Spatial Technologies Agribusiness Education and Training Other (please specify below) Other:Briefly describe your business and your export strategy?*At what stage of exporting is your business currently at?*Mentoring requiredIssues/challenges to discuss with the Mentor:* International Strategy / Export Planning International Marketing / Communications Finance / Capital Raising HR / Recruitment Intellectual Property Legal – International Business Structures Legal - General Other (please specify below) Other:What ongoing mentoring would you like to be involved in?What other international business development issues do you have?What do you find as the most challenging aspect of growing your international presence in the short term?*What do you find as the most challenging aspect of growing your international presence in the long term?*What contact have you had with Trade Support programs eg ACT Government, Austrade (TradeStart Program), Canberra Business Chamber (CBC), Other?*Signed Certification*Please submit a signed copy of the certification agreement, which can be downloaded herePhoneThis field is for validation purposes and should be left unchanged.