MEMBER INFORMATION      

Name: Title:  

Company/Organization:

Year Established:

Address:

City: State: Zip:

Phone: Fax:

 E-Mail: Website:

 Average Number of Employees: Type of Business:

Certifications (SBA 8(a), Regional Purchasing Council, etc.):

  Do you export? Yes No

Products or services? From: To:

  Principal Clients:

  Is your firm a Hispanic Business Enterprise ? (at least 51% Hispanic owned and operated) Yes No

Please attach a brief corporate profile, including a company history and a description of your products/services

 MEMBERSHIP CATEGORIES

 Please indicate your membership category:

1-10 Employees ………………………………….…………………………..............$100.00

11-25 Employees ………………………………….……………………….........…...$250.00

 25-50 Employees ……………………………………………………………………..$500.00

 50+ Employees ………………………………….…………………………...............$750.00

 Clergy (any) ………………………………….………………………….....................FREE

 Exec Directors-Small Non-Profits ………………………………….……………..FREE

 College Students …………………………………………………………………….FREE

 My/our primary interests: (check all that apply):

Health Insurance
Networking Opportunities
Educational Workshops/Seminars
Group Discounts/Benefits
Committee Involvement
Marketing/Advertising Opportunities
Sponsorship
Legislative