Membership Request Form

Thank you for showing interest in our membership programs! We are excited to learn more about you. Please review the membership packages and fill out the form below to begin the application process and schedule your interview.

If you have already been interviewed please upload a headshot photo (of high resolution quality).

FULL NAME *

Prefix First Name Last Name

BUSINESS NAME:

WEBSITE

PHONE NUMBER *

Area Code Phone Number

E-MAIL *

What is the best way to contact you?

What is the best day to contact you?

What state or country is your business located?

What membership/ network are you inquiring about?

Have you already been interviewed?

Are you a speaker or coach?

Speaker Only: What topics do you speak on?

What products or services do you offer?

Coaches Only: What areas do you provide coaching?

What challenges do you face in your business?

What size t-shirt do you wear?

How do you want your t-shirt delivered?

Shirt : If you selected mail option please enter the address you want us to send it to.

What Social Media platforms can we connect with you?(please include the links)

Do you want to be entered into the Business Directory?

Do you want us to connect you with a accountability partner?

Do you want to be entered into our Coaching Network? (As part of the coaching network you agreed to be paid $50 for 30 minute of coaching for any member of the organization that goes through hour link on the website to book your services.)

Coaching Network: If you stated "YES" to the previous question above then please lists the days and time you are avail for coaching during the week or on weekends.

Why are you interested in becoming a member of this organization?

Do you want to be added to our affordable coaching / consultant network to get paid for $50 for 30 min of coaching session or $75 for every 30 min of consulting session when someone in our network or organization books your services?

If yes, which do you want to be entered into?

If yes, what hours and days are you available to provide coaching / consulting services?

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