Membership Application

First Name (required):

Middle Initial:

Last Name (required):

Company Address


Company Name (required):

Company Address (required):

City (required):

State (required):

Zip (required):

Phone:

Fax:

Mailing Address (Optional)


Mailing Address:

City:

State:

Zip:

Contact Info


Website:

Email (required):

Home Phone:

Other Phone:

Business Info


Business Start Date:

Type of Business (required):

% of Ownership (required):

# of Employees:

Category of Business (required):

Description of Business (required):

About You


Education:

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Photo Release - I hereby grant permission to the rights of my image, likeness and sound of my voice as recorded on audio or video tape without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product, wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. Photographic, audio, or video recordings may be used for the following purposes: marketing, informational presentations. By checking yes for this release I understand this permission signifies that photographic or video recordings of me may be electronically displayed via the Internet or in a public setting. I will be consulted about the use of the photographs or video recording for any purpose other than those listed above. There is no time limit on the validity of this release, nor is there any geographic limitation on where these materials may be distributed. This release applies to photographic, audio or video recordings collected as part of my involvement with Women Business Owners of Michiana. By checking yes for this release I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for the purposes listed above.

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