Application for Membership

Date:

Sponsor:

Name:

Home Address

Zip Code

Home Phone

Significant Other

Business Name

Business Address

Business Phone

Cell

Fax

Email Address

Corporation

Partnership

Sole Proprietorship

Your Position

How Long?

Your Responsibilities

Names & Titles of other corporate officers, partners, principals

Number of years business has been in operation

Other Businesses you have been, or are, associated with (if present employment less than five years)

List all products sold and services performed by your firm

Please list BIC members with whom you are acquainted

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