Membership Form

Name*

First NameLast Name

Todays date*

Date

Business Name*

Mailing address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Business Address if different then above

Street Address

Street Address Line 2

CityState / 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 CodePhone Number

Business Genre*

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. *

Additional Chapters you would like to get notices from

Yearly Memberships*

Yearly Small Business Membership($200.00 for each year)

Memberships that have a business.

Yearly Major Gold Partner Membership($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 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 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 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 for each year)

I agree to {terms & conditions}. *

Signature*

Additional Information