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Membership Application

First Name

Job Title

Business Number

Last Name

Email

Phone Number

Business You're Representing

Business Address

If you were to leave the group, who would we contact? (Name and Phone Number)

Primary product or service you are representing:

Secondary product or service you are representing:

Please describe your product or services you are planning on representing:

Please list two references that we may contact (Name, Business Name, Phone Number):

Do you belong to other networking organizations? If so, please list:

Are you able and willing to commit to arriving on time at the weekly meeting, stay throughout the entire meeting, and not missing more than 12 meeting's in a year, and more then 2 meetings in a row. Required

Yes

No

Applicant may cancel their membership within 3 days of signature date and receive a full refund. No refund of original payment will be given after 3 business days. Required

I agree to the above requirements.

Applicant agrees to be a member in good standing (to not miss more meetings then allowed and pass at least 24 referrals in a 12 month period of time). Required

I agree to the above requirements.

WAIVER OF LIABILITY, INDEMNIFICATION, AND HOLD HARMLESS AGREEMENT. Applicant understands that the pREFERred Networking board is not liable for the conduct of any individual that causes harm or injury and hereby agrees to RELEASE, WAIVE, and DISCHARGE pREFERred Networking from any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or related to any loss, damage, or injury that may be sustained by Applicant, or to any property belonging to Applicant, while participating in any activity associated with pREFERred Networking, while in, on or upon any premises where the activities are being conducted, REGARDLESS OF THE INJURY OR CAUSE. This clause shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. Required

I agree to the above requirements.

I will provide quality service, be truthful with members, have a positive and supportive attitude, and follow the ethical standards of my profession while I am a part of pREFERred Networking. Required

I agree to the above requirements.

I understand that if I do not follow these guidelines that my membership renewal may be denied. Required

I agree to the above requirements.

Electronic Signature

Thanks for submitting!

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