Membership Application Form

I agree to abide by the by-laws of the North Coast Business Network regarding attendance and procedures.  I am also aware that only one person in each business category is permitted, and that my application is subject to approval by the existing group.

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Signature

Date

Business Category 

Please write category description for your name tag (max. 22 characters):

 Name: First        Last                   

        Business Name

Business Street Address                Suite #

City                             State        Zip

(        )                        (        )_________ Business Phone             Home Phone  

(        )______________ Fax 

e-mail

What is your position with this business?

Do you have any special licensing or certification?

Length of time in this profession?

Length of time with this company?

A one time set up fee of $35. Dues are $30 per quarter. (If you join mid quarter your dues are only for the months of the quarter still remaining.) Please enclose a check with your application and bring it to the next meeting.

website

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