Applicant's First Name

Applicant's Last Name

Cell Phone *

Email *

Business Name

Business Category

Business Website Address

Business Address

Describe your product or service: (please be specific)

Experience in field/occupation: (please be specific)

Education/ background in field/ occupation, degrees, licenses or credentials required to perform in your field/ occupation:

Is the occupation under which you are applying for membership your full-time occupation?

Yes

How long have you been in your current occupation?

Are you able to make the commitment to arrive on time and stay throughout our meetings?

Yes

Are you able to attend meetings two times a month? (1st and 3rd Tuesday)

Yes

Is there an individual(s) who would be willing and able to attend meetings on your behalf, should be be unable to attend?

Yes

Please describe how the acceptance of your membership will be beneficial to the success of this chapter:

Are you willing and able to bring quality referrals and visitors?

Yes

Please list and charities and/or non-profits you are involved in, or would be interested to be involved with:

Option 1
Option 2
Option 3
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List Two business references: (please include name, job title, business, phone number, email and business relationship)

Who invited you to this chapter?

1. A prospective member may attend three (3) meetings as a visitor. Prospective members must then complete an application and submit it with payment to the membership committee for review.
2. The membership committee will begin the screening process (references, etc)
3. Upon acceptance, all fees are non-refundable without exception.

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