Business Empowered Mississippi Partnership Application

Business Empowered Mississippi Partnership Application
I am a... (Check one of the following)

New Partner Existing Partner
Name

First Name Last Name
Title/Position
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Email
example@example.com
Business/Ministry Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Main Phone Number

Area Code Phone Number
Fax Number

Area Code Phone Number
Email
example@example.com
Website
Company Contact 's Name
Phone Number

Area Code Phone Number
Email
example@example.com
Number of Employees
Date Business/Ministry Started
Upload your picture and/or logo.

Browse Files
JPEG OR PNG FILES ONLY Cancel of
Reason for Partnering (Check all that apply)

Personal Growth & Development Professional Growth & Development Spiritual Growth & Development Special Events Educational/Training Programs Increase Visibility Networking Opportunities Speaking Opportunities Coaching Opportunities Volunteering/Leadership Opportunies Team Building Opportunities Prayer Covering for You & Your Business Business Building Training & Development
ANNUAL PARTNERSHIP INVESTMENT: FOR FACTS AND DETAILS ON YOUR PARTNERSHIP LEVEL, PLEASE GO TO WWW.BEMISSISSIPPI.COM.

Individual - $100.00 Couples - Husband and Wife Only- $150.00 VIP (Vitality Investment Partner - 2-4 Employees) - $300.00 SOAR (Success Objectives Achievements & Revalization - 5 - 9 Employees) - $500.00 The BEST (Business Empowered Success Trailblazers) of MS Bronze - 11 - 24 Employees) - $1,500.00 The BEST (Business Empowered Success Trailblazers) of MS Silver - 25 to 50 Employees) - $2,500.00 The BEST (Business Empowered Success Trailblazers) of MS Gold 51 to 100 Employees - $5,000.00 The BEST (Business Empowered Success Trailblazers) of MS Platinum - 101 -250 Employees - $7,000.00 The BEST Corporate (Business Empowered Success Trailblazers) of MS Bronze - 251 -350 Employees - $8,500.00 The BEST Corporate (Business Empowered Success Trailblazers) of MS Silver - 351 -500 Employees - $10,000.00 The BEST Corporate (Business Empowered Success Trailblazers) of MS Gold - 501 -750 Employees - $12,000.00 The BEST Corporate (Business Empowered Success Trailblazers) of MS Platinum - 751 - up Employees
Need Payment Plan Option? Pay half now and final payment due in 4 weeks upon receipt of registration.

Yes No
Mail your check or money order to: Business Empowered Mississippi, Attention: Partnerships, P.O. Box 2683, Madison, MS 39130 OR choose payment option below.
My Payment Amount: *

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USD Annual Partnership Fee

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