Application – Referral Madness

Referral Madness is a seat specific group, meaning only one person can represent a field/profession/business.

Date Visited

Chapter you are interested in?

Name*

First Last

Phone*

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Business Name*

Owner*

Yes
No

Business Address*

Street Address Address Line 2 City State ZIP Code

Position Title

Business Email

Business Phone #*

Describe your experience in your field. How long have you been in the business? How long have you been with the company you represent?*

Describe your educational background with your field. Please include licenses. credentials, etc.*

Is your occupation full or part time?*

Full time
Part time

Business category applying for as member seat*

Have you participated in networking groups in the past?*

Yes
No

Are you a member of another group presently?*

Yes
No

If yes, please specify

Business References

Name*

Position*

Phone*

Business Name*

Relationship*

Business References

Name

Position

Phone

Business Name

Relationship

Membership Roles

As a growing group it takes a great team to be successful. What leadership roles are you interested in contributing to in the future? (Check all that apply)

Roles

How did you hear about us?

I agree to live up the ethical standards of my industry*

I will promptly follow up on referrals I receive*

I am committed to being on time to the meeting*

I am willing to commit to doing meet-ups with members on a regular basis to learn more about how I can help their business grow and to let them know what type of referrals or strategic partners would benefit me*

I am committed to send a substitute person in my place when I will be absent. Please list 3 subs that will to attend in my place. They don’t need to be in your company.*

Sub #1 Name and Relation*

Sub #2 Name and Relation*

Sub #3 Name and Relation*

Automatic Renewal: Your membership with Referral Madness shall be automatically renewed and your payment method on file charged, upon like terms for successive calendar year periods unless you notify Referral Madness in writing no longer than 30 days prior to the anniversary of your joining date(The date of your first payment to Referral Madness).

I've read and agree to the Referral Member Guidelines and Policies located here*

Signature*

Date*

Name

This field is for validation purposes and should be left unchanged.

READY TO JOIN?

Business References

Business References

Membership Roles