EmailMe Form - QueenLyfe Inc. Membership Application

Name

First Last

Business/Agency/Organization

Title

Mailing Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Email

Telephone Number

### - ### - ####

Date of Birth

MM / DD / YYYY

Marital Status

T-Shirt Size

Please upload a current headshot photo.

Why are you interested in becoming a member of QueenLyfe Inc.?

What areas of expertise and or contributions do you feel you can contribute as a member of QueenLyfe Inc.?

Do you have other Membership Affiliations? If yes, please list below.

Please select your areas of interest.

Membership Dues

All QueenLyfe Members are required to pay annual Membership Dues. Dues are necessary for the continuous operation and function of the QueenLyfe Inc. organization as budgeted. Annual due dates are set for the fiscal year ending in December. Annual Membership Dues are non-refundable.

Membership Type

Individual/Professional - $100 annually

Small Business (1-10 employees) - $250 annually

Emerging Business (11+ employees) - $750 annually

Corporation - $1,000 annually

Cardholder Name

First Last

Debit/Credit Card Number

Expiration Date

MM / YYYY

CVV

Billing Zip Code

Authorization

I confirm that the all the above information is provided in truth. I understand that falsifying any information will result in termination of the application for membership with QueenLyfe Inc. indefinitely and I may not re-apply. I also authorize QueenLyfe Inc. to process payment information provided for the membership level selected above.

Signature

Clear