LCN Application Form 2012

Name: Company
Name: Company
Name: Company
Name: Company
Date:
Address

Street Address

Street Address Line 2

City State ZipState / Province

Postal / Zip Code
Main Phone
2nd Phone
Email
example@example.com
Sponsoring Member
Websitehttp
Twitter
Classification: Choose from attached list
FB Biz page
1st Choice
2nd Choice
3rd Choice
1. Experience in field/occupation: be specific
2. Education background in field/occupation; i.e. degrees, licenses, or credentials required
2. Education background in field/occupation; i.e. degrees, licenses, or credentials required

3. Is this yourfull time orpart-time occupation?
2. Education background in field/occupation; i.e. degrees, licenses, or credentials required
4. How long have you been in business or with your current company.
Yes! I am willing and able to attend the weekly meetings.

5.
6. What do you expect to contribute to this chapter?
7. What is your ability to bring qualified referrals or visitors?
continue on reverse
This application is good for one year, must reapply each year of membership, unless member quits for period of six months or more.

I hereby declare and certify that all statements contained in this application are true and correct, and that any misrepresentation or false statement may be grounds for rejecting my application
Name
Position
Company
Phone
Business Relationship
Email
example@example.com
Name
Position
Company
Phone
Business%Relationship
Email
example@example.com
UPON YOUR ACCEPTANCE, FEES ARE NON-REFUNDABLE
Verified Information and References:

If declined, what were the reasons? Was there conflict with job description of an existing member?
Should be Empty:

UPON YOUR ACCEPTANCE, FEES ARE NON-REFUNDABLE