Membership Form COMPANY NAME TITLE SelectMr.Mrs.Ms. CONTACT PERSON/S MAILING ADRESS WEBSITE TRADE NAME DEPARTMENT PHONE 1 PHONE 2 E-MAIL FAX MOBILE DESCRIPTION OF THE COMPANY MISSION ESTABLISHED DATE Day01020304050607080910111213141516171819202122232425262728293031 / Month010203040506070809101112 / Year196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013 YEARS OF OPERATION Invalid Input NUMBER OF EMPLOYEES Invalid Input ANNUAL INCOME ($) Invalid Input Future Goals SHORT TERM LONG TERM SCOPE OPERATION Individuals Community Nationwide Regional Global/International Invalid Input PRODUCTS AND SERVICES Manufacturing Export/Imports Retails Agriculture/Forestry Food Industry Education Transportation Energy Environment Airlines/Travel Industry Hospitality Industry Hospitals/Health Care Real Estate/Land Dev. Banking/Financial Advertising / Media News / Magazines Printing / Publications Entertainment Government Think-tank / Policy Chamber of Commerce Consulting Charity / Foundation Development Agency Local NGO / INGO others Invalid Input MEMBERSHIP OPTIONS Basic Platinium Exchange (in kind) Silver Specialized Service Pay-as-you-go Gold Extra Service Non-Member Service Invalid Input Choose payment option Bank Draft/Cheque/ Paypal AMOUNT Select Silver - $1,000.00 USD Gold - $2,000.00 USD Platinum - $3,000.00 USD Invalid Input Total USD $0.00 Invalid Input Submit
