Membership Long Form

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Please complete the application below asap. Once completed, we will contact you for a personal interview.

Long Application

Chapter

Stuart

PSL

First Name:

Last Name:

Email:

Phone:

Title

Business Name

Business Phone:

Cell Phone

Website:

Email:

Referring Member Name

How do you know this member?

Describe your experience in your field:

Length of time in your industry

Educational background in Industry/Category or Degrees, current Licenses or Credentials required to perform in Industry/Category (list school/state and/or business/state):

Has your professional license ever been revoked or suspended?

Yes

Please explain if Yes:

Are you committed to bringing referrals and/or visitors to this chapter?

Yes

Do you belong to other networking groups?

Yes

Please List:

Business Reference #1

Business Reference #2