Application (IS)

<br /> Chapter Member Application<br />

Contact Information
First Name *
Last Name *
Company *
Office Phone
Mobile Phone
Email *
Chapter *
Chapter Category *
Metro Area *
Other Information
Describe your business
How long have you been working with the company listed above?
How long have you been in the industry?
Describe your ability to bring leads or visitors to your chapter:
Do you agree to commit to the attendance policy and Code of Ethics as listed in the guidelines?
Do you have a possible Substitute to attend in your stead if you are unable to attend?
Do you belong to other networking organizations?
If yes please list:
Please list first business reference name:
Describe business relationship with reference one:
Reference one business:
Reference one position:
Reference one phone:
Reference one email:
Please list second business reference name:
Describe Business Relationship with reference two:
Reference two business:
Reference two position:
Reference two phone:
Reference two email:
Please list a Pastor reference name: (can be Small Group leader)
Pastor position:
Pastor Phone:
Pastor Email:
Billing Address
Company Street Address *
Street Address 2
City *
State *
Postal Code *
Shipping Address
Leave blank if same as above
Street Address 1
Street Address 2
Postal Code
Credit Card Information
Card Type *
Card Number *
Expiration Month *
Expiration Year *
Subscription Purchase

Chapter Member Annual Dues
$200.00 every Year
$200.00 every Year
Shipping Option
Total Amount You Pay Right Now

I have read and understand the terms of this agreement.
(Enter your initials)
Please enter the Security Code shown below:

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