Coastal Connections Application

What is your full name? *

What is your email address? *

What is your job title? *

What is your best number? *

What industry are you in? *

How many years of experience? *

What chapter are you interested in joining? *

How did hear about us? *

Have you been a member of a networking group before? *

Yes

No

What motivated you to join our networking group? *

Which days of the week are you available for meetings? *

Do you have any specific skills or expertise you would like to share with the group? *

What do you hope to gain from being a member of our networking group? * 🛈

Dues Preference *

Name on card *

Card number *

Expiration *

CCV *

Billing Address (include City & Zip) *

I agree that my details and data will be collected and stored securely! The membership dues if signed up, Mid Quarter will be prorated per the revolving quarterly calendar. Dues can be paid via check payable to Coastal Connections Community or via credit card entailing a transaction fee. Payment Link will be reoccurring every 1st month of the quarter.

QUARTERLY DUES- $150
ANNUAL DISCOUNTED DUES $550

Agreed

Signature of Membership *

clear