Membership Application

Company Information

Nominated By:

Name:

Date:

Position/Title:

Company Name:

Address:

City:

State:

Zip Code:

Work Phone:

Mobile Phone:

Email Address:

Birth Date: - - Select - - JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember - - 12345678910111213141516171819202122232425262728293031

Website Address:

Type of Business:

Description of Business and Products/Services Your Company Provides:

Years in Business/Profession:

Number of Employees:

Personal Information

Home Address:

City:

State:

Zip Code:

Home Phone:

Home Email Address:

Professional Exprience

Do you currently serve on the Board of Directors of any companies or non-profit organizations:

Yes No

If yes, please list:

List any professional organizations, trade groups, chambers of commerce, community organizations or networking groups you belong to:

Describe the individuals and/or professionals you know that you anticipate inviting to CWI from your existing relationships:

What you seek from CWI

What are you looking for by being involved in CWI? (Examples: Referrals, business/colleague partnerships, connections to other business professionals, career connections, etc.):

Type of Membership Applying For

Professional Level Membership:
Annual Membership Fee:$350
Monthly Dues:$69

Executive Level Membership
Annual Membership Fee:$350
Monthly Dues:$200

Payment Information

Upon membership vote and acceptance, a credit card will be required for payment of annual membership fee and monthly dues.

Signature & Agreement

By submitting this application, I certify that all information is true and complete to the best of my knowledge. I hereby apply for membership in CWI and have read and understand the qualifications of membership and membership dues and fees. I understand that I may terminate my membership in CWI at any time with prior written notice and understand that the annual membership fee and monthly dues are nonrefundable. Upon submission of my membership application, I will receive notification of my acceptance into CWI and understand that membership is exclusive to the individual, not the organization. I further understand that my membership application may be denied after review and consideration and that my membership application is not a guarantee of acceptance. Upon membership approval, the annual membership fee and monthly membership dues are charged via credit card for the current month. Future monthly dues are charged on the first of each month. If membership is not accepted, no charges will be due or paid.