Membership Application

Designated Representative Change*
- Yes
- No
Executive Network Organization
Distinguished Honorary Members Claude King, David Menz, Jim Sculley and Morris Mitchell

To Sponsor: This application must be approved by the Membership Committee, the Board of Directors and the Membership-at-large before an invitation to join can be extended. To avoid embarrassment, it is recommended that you be discrete in membership discussions with the prospect and avoid premature representations of acceptance.
Proposed Member*
First Last
Position*
Proposed Category*
Firm Name*
Business Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Business Phone*
Mobile Phone
Fax
Email*
Business Website*
Type Of Organization:*
PROPRIETORSHIP
PARTNERSHIP
CORP PRINCIPALS:*
Nature Of Business:*
PROPOSED COMPANY’S YEARS IN BUSINESS:*
Number Of Employees:*
PROPOSED CLASSIFICATION:*
Spouse/Partners Name
First Last
Spouse's Occupation
Business Interests Other Than Above*
Other Leads/Business Groups Memberships Held By You*
Other Leads/Business Groups Memberships Held By Your Business*
Sponsors Name*
First Last
Date*
MM slash DD slash YYYY
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