Membership Form
Name
*
First Name
Last Name
Todays date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Business Name
*
Mailing address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Address if different then above
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referred by
Email of the person that referred you, this way we can give them proper credit
example@example.com
Business Number
*
-
Area Code
Phone Number
Business Genre
*
ACCOMMODATION
ADULT
ADVERTISING
ART
AUTOMOTIVE
BANKING
CONSTRUCTION
DOMESTIC SERVICE
EDUCATION
ENTERTAINMENT
FINANCE
FLOORING
FOOD & BEVERAGE
GENERAL
GOVERNMENT
HAIR & BEAUTY
HEALTH & WELLNESS
HOSPITALITY
LANDSCAPE
MARKETING
MEDICAL
MUSIC
PROFESSIONAL SERVICES
NONPROFIT
RELIGION
PUBLIC RELATIONS
RETAIL/WHOLESALE
SPORTS
TECHNOLOGY
TELECOMMUNICATIONS
TELEMARKETING
TRADE
TRANSPORTATION
TRAVEL
UTILITIES
WEBSITE DEVELOPMENT
Short Business description
*
Long Business Description
Business E-mail
*
Business web page
Your annual membership covers ALL 15 Chapters. Please select which chapter you plan to network with most often.
*
Barstow
Beverly Hills
Culver City
High Desert/Victorville area
Hollywood and surrounding cities
Inland Cities East/San Bernardino area
Inland Cities West/ Rancho Cucamonga area
Inland Valley/Temecula area
Lancaster / Palmdale
Long Beach area
Moreno Valley and surrounding cities
Palm Springs
Pomona and surrounding cities
Riverside Cities and surrounding cities
San Gabriel Valley/ Pasadena area
Additional Chapters you would like to get notices from
Barstow
Beverly Hills
Culver City area
High Desert/Victorville area
Hollywood and surrounding cities
Inland Cities East/San Bernardino area
Inland Cities West/ Rancho Cucamonga area
Inland Valley/Temecula area
Lancaster / Palmdale
Long Beach area
Moreno Valley and surrounding cities
Palm Springs
Pomona and surrounding cities
Riverside Cities and surrounding cities
San Gabriel Valley/ Pasadena area
Yearly Memberships
*
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( X )
Yearly Small Business Membership
(
$200.00
$
200.00
for each
year
)
Memberships that have a business.
Yearly Major Gold Partner Membership
(
$5,000.00
$
5,000.00
for each
year
)
1 major e-blast every month (over 1,500 addresses) for 12 months, 1 full page ad in newsletter for 6 months, Partner Membership ID card, one listing in business directory with logo and website link, $2,500 of local discounts, open access to all mixers, and 50% off entry to all special events
Yearly Silver Corporate Membership
(
$2,500.00
$
2,500.00
for each
year
)
1 major e-blast for 4 months (over 1,500 addresses) per month, 1 full page ad for 4 months in newsletter Corporate Membership ID card, one listing in business directory, $2,500 of local discounts, open access to all mixers, discount on special events
Yearly Bronze
(
$1,500.00
$
1,500.00
for each
year
)
Business Membership ID card, 1 Quarter page ad in newsletter for two months, one listing in business directory, $2,500 of local discounts, 1 major e-blast (over 1,500 addresses) per month for 2 months, open access to all mixers, discount on special events
Yearly Partnership Membership
(
$1,000.00
$
1,000.00
for each
year
)
Access for 2 staff members2 Membership ID cards, half page ad in newsletter, listing in business directory $2,500 of local discounts, open access to all mixers, discounts on special events.
Yearly Nonprofit
(
$150.00
$
150.00
for each
year
)
I agree to {terms & conditions}.
*
Signature
*
Additional Information
Credit/Debit Card or PayPal Payment
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