Full Questionnaire BRC Membership Form

BRC 2024-2025 Individual Membership
View Individual Membership benefits here.
Name*

First NameLast Name
Email*
Please enter a valid email address
LinkedIn Address
Mobile Phone #*
Please enter a valid phone number.
Title
Company
Either your primary board or your current employer
Industry
Either your primary board or your current employer
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Please fill in the information about any boards and their committees on which you currently serve.
Are you a board director? If so, add name and title below.
Board Name / Title
Are you a member of a committee of the board listed above? If so, add name of the committee and your title below.
example: Risk Committee / member
Would you like to add another Board you serve on?

YesNo
Board #2 - add board name and your title
Board Name / Title
Are you a member of a committee of board #2 listed above? If so, add name of the committee and your title below.
example: Risk Committee / member
Would you like to add another Board you serve on?

YesNo
Board #3 - add board name and your title
Board Name / Title
Are you a member of a committee of board #3 listed above? If so, add name of the committee and your title below.
example: Risk Committee / member
Would you like to add another Board you serve on?

YesNo
Board #4 - add board name and your title
Board Name / Title
Are you a member of a committee of board #4 listed above? If so, add name of the committee and your title below.
example: Risk Committee / member
Would you like to add another Board you serve on?

YesNo
Board #5 - add board name and your title
Board Name / Title
Are you a member of a committee of board #5 listed above? If so, add name of the committee and your title below.
example: Risk Committee / member

Membership Choices*

Individual Membership Product Image

Individual MembershipMid-year Membership - now through June 30, 2025

$200.00

Total

$0.00

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