Associate Membership Proposal

Section 1

Member Firm

Date

Proposed Associate Members Name

Title

Company Address

City

State

- Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip

Company Phone

Company Fax

Cell Phone Number

Company Email

Home Address

City

State

- Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip

Home Phone

Spouse’s Name

Home Email

---

Section 2

Identify Postion Within Company

Owner

Partner

Second in Command

Third in Command

Executive with Administrative duties and discretionary authority

Brand Representative in charge of Agency or Branch in an Executive or Administrative capacity with discretionary authority

How long have you been with the company?

Detail your decision making authority

Prospect agrees to attend 50% of the regular meetings?

Yes

No

Prospect agrees to attend 50% of the open houses?

Yes

No

Ability to provide direct and indirect leads?

Yes

No

Do you currently belong to any Broward County Business networking organization?

Yes

No

If yes, which one(s)

List all clubs or business associations and office held for the past 5 years

Education Background

---

Section 3

Sponsor

Sponsor Firm Name

I have known Prospect for years.

Business

Social

Why do you think Prospect is best in their field?

Signature of Sponsor

Reset

Submit