Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Welcome In Program Application Welcome In is a pilot program that recognizes businesses for creating safe and welcoming environments free from discrimination and harassment of customers. The Civil Rights Department (CRD) has established this program pursuant to Civil Code section 51.17. Application Section 1 Primary Business Contact *FirstLastPrimary Contact Email *Business Title (e.g. CEO, Owner, Manager) *Primary Contact Phone *Which days of the week are best for contacting you? Select all that apply.MondayTuesdayWednesdayThursdayFridayWhat time of day is best for contacting you?Morning 8 am - 12 pmAfternoon 12 pm - 5 pmPreferred Method of Contact *EmailPhone Primary Business Information Legal Name of Business *Primary Business Phone *Business Website / URLHours of Operation *DBA or any other names used for this businessSecretary of State ID, Seller’s Permit, City/County Business Tax Registration or License, or EINName of Business Owner *FirstLastBusiness Street Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeBusiness Mailing Address (if different)Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code Other Business Locations Are there other business locations you wish to add? *YesNoLegal Name of Additional BusinessAddress of Additional BusinessAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code Add Remove Type of Business What is your primary business activity? *Accounting/BookkeepingAgricultureAutomotive ServiceBoutique/Gift shopCafé/Coffee shopCleaning/Home MaintenanceConstruction FirmConvenience storeE-commerceEducational ServiceElectronics storeEvent Planning ServiceFarm/Pet SuppliesFinance/InsuranceFine Dining EstablishmentFitness IndustryGas StationGrocery StoreHardware StoreHealth Care ServiceHome Improvement ServiceHotel/MotelLandscape/GardeningLegal ServicesNonprofit OrganizationPersonal Care ServicePet care/Pet SuppliesPharmacyReal EstateRestaurantTechnology CompanyRestaurantRetail StoreThrift StoreTransportation and LogisticTravel AgencyWholesaleOtherPlease describe in detail the goods and/or services you provide. *What is the average number of customers/visitors that your business serves each day? *How many supervisory employees do you have? *When was your business established? *How many non-supervisory employees do you have? * Application Section 2 Why are you interested in Welcome In, and how do you believe this program will contribute to your business and your community? *(1-3 sentences)In the past year, how many incidents of discrimination, harassment, or hate between customers or other members of the public occurred at your business? (for example, a customer calling another customer a racial or homophobic slur)Never1 to 5 times5 to 10 times10 or more times Application Section 3 How did you hear about this program? *WebsitePresentationOutreach EventSocial Media AdOtherOther *Are there any other business you recommend for the Welcome In program?Please certify that you agree to the following statements. *I am authorized to represent the business described in this application and the business is able to participate in the Welcome In program.Certify Question 2 *I have reviewed the program requirements and will complete them within one year of acceptance into the program.Certify Question 3 *The information provided in this application is true and accurate to the best of my knowledge.Certify Question 4 *Participation in Welcome In does not shield the business from liability under California civil rights laws.Date *Submit
