New Member Application
PDF Application
Name:
Home Address:
City: State: Zip:
Home Phone:
Title:
Business: Business Address:
Business Phone: Business Fax:
Last 4 digits of your social security # (your ID# is this + your initials)
Email: (payment confirmation to be sent here, please verify)
How did you hear about EMBN? Another Member Website Advertisement Attended a function Other
Why do you want to join Empower Me! Business Network?
Do you know of any other women who might be interested in joining EMBN? Yes No
Payment Information
Debit/Credit Card- (Once you submit your application, you will be directed to Paypal.com to complete your transaction securely. You do not need an account to pay with Paypal.)
Amount Due: Mail this completed form and payment to:
Empower Me! ATTN: Empower Me Business Network Membership P.O. Box 863, Alpharetta, GA. 30009-0863 or fax to: 253-559-4028
Email and fax applications will be accepted only when paying by credit card or online check. Application confirmation will be sent via email so please ensure you list the correct email address. Please allow two weeks for processing from the date of receipt of your application.
No cash will be accepted. One application per person. Membership is valid for one year, and is non-refundable. Renewal is not automatic. The entire cost of your membership cost is used to underwrite the EMBN. Your membership is national. If you choose, you may apply for membership to a local chapter with no additional cost. Each chapter is run independently and has its own guidelines, agenda and protocol. However, all chapters are governed by the by laws of the national EMBN office. Chapter membership is optional at this time. However, to gain the most benefits from the network, you should affiliate with a local chapter if available. Membership fees are non-refundable. Returned check fee is $35. All information is held confidential and will not be sold to third parties. Only our approved sponsor companies will be sending you information about their services or products. When a new sponsor is added, we will inform members before allowing information to be sent to our members. You must supply your membership number to receive member discounts. EMBN does not tolerate spamming or false representation of EMBN or Empower Me! Any member found violating our policies, will have their membership terminated immediately. Please review your membership rights and responsibilities when you receive your new member packet.
Please print this form before submitting and keep for your records. DATE Electronic Signature
For all inquiries, call the Member Support Center (678) 698-6206 or email: Member Services.
Copyright 2002-2006 Empower Me! Networks. Networks for Empowered Black Women™ All Rights Reserved.
