Corporate Partners
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Please Fill Out the Form below or Click Here to Download the Printable PDF form
   
Business Name
Address
City State    Zip
Business Phone
Business Fax
Email Address
Website
   
Type of Business
HealthCare Attorneys/Law Firm
Restaurant Telecommunication
Financial Institute Realtor / Mortagage Broker
Other (please specify)
Number of Employees
   
Name of Rep 1
Title Ext. Email
   
Name of Rep 2
Title Ext. Email
   
Could You Extend Discounts to Members?     Yes    No
   
Type of Discount
and How Much
   
   
Referred By
   
Membership Fees per year
 Non-Profit Organization...............................................................................$100.00
Small Business / Professional (1 to 4 employees)...............................$150.00
Medium Business / Corporation (5 to 19 employees)...........................$300.00
Large Business / Corporation (20 or more employees).......................$500.00
Corporate Partners.......................................................................................$2000.00
   
Cardholder Name
Card Type
Card Number Expiration Date
Signature (please type full name)
Date Signed

Please Call 954.961.6386 with any questions or fax the downloadable form to 954.961.8319


Click here to Download the
Membership Application &
Credit-Card Payment Form
 
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