NIAX Application Form
Legacy Groups
Full Name
*
First Name
Last Name
Title
*
Ex: Owner/President/Manager
E-mail
*
example@example.com
Application Date
*
-
Year
-
Month
Day
Date
Company Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Work Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone Number
*
Format: (000) 000-0000.
Website
www.abccompany.com
Membership Selection
Application Fee of $200.00 is set. Please select one subscription option.
Membership Fee
*
Monthly Fee (Exclusive) $249.00
Monthly Fee (Standard) $125.00
Annual Fee (Exclusive) $2949.00
Annual Fee (Standard) $1500.00
Non-Profit 0.00
Which Group do you Prefer?
Please Select
Legacy Builders (Central)
Legacy Connectors (West)
Legacy Leaders (South)
Credit Card Information
We will contact you for the card information after receiving your application.
Billing Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Industry Experience
Business Classification (Be Specific)
*
1. Experience in Business Classification (Be Specific)
*
2. Education, Degrees, Licenses, or required credentials:
*
3. Have you ever had your license revoked or suspended?
*
No
Yes
If yes, provided details:
Commitments
Please note that by completing this section and electronically signing this application, you are entering into a binding contract with NIA and Cougar Connection, LLC.
1. Are you willing to commit to attend our monthly meeting, arrive on time and stay for the 90 minutes, make referrals when appropriate, and abide by NIA policies, guidelines and code of ethics?
*
Yes
No
2. I understand that I am committing to a 12 month period. (Initial)
*
Initial
3. Do you belong to other networking organizations?
*
Yes
No
If yes, please list:
4. I understand that a background check is require. (Initial)
Initial
Signature
Signing your Name constitutes agreement to this Contract.
Printer Name:
*
Signed Date:
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: