Application - Professional Connections Group

Member Information

Date*

Applicant's Name*

First Last

Product or Service Category*

Business Name*

Business Address*

Street Address Address Line 2 City State ZIP Code

Business Phone*

Cell Phone*

Email*

Website*

Sponsor's Name*

First Last

Member Commitment

Is the occupation under which you are applying for membership a full or part-time occupation?*

How long have you been with the company you are representing today?*

Are you able and willing to make the commitment to arrive at our weekly meeting and be on time and stay throughout the entire meeting?*

Is there an individual in your company who would be willing and able to attend meetings on your behalf, should you be unable to attend?*

Will you be able to bring qualified referrals and visitors?*

Are you a member of any other Networking Groups?*

Yes

No

Which One/s?*

Personal Information

Home Address*

Street Address Address Line 2 City State ZIP Code

Birthday*

Spouse Name

First Last

Anniversary

Children Name(s)

Business References

Name*

First Last

Business*

Phone*

Business Relationship*

Name*

First Last

Business*

Phone

Business Relationship*

Applicant's Signature*

Date*

Application Fee

Price:

Dues

Price:

Payment Method*

Credit Card

ACH (Checking/Savings)

Credit Card Transaction Fee

Price: $0.00

Total

Please Make Sure You Switch To ACH Payment To Remove Fee ↓

Credit Card*