BEX MEMBERSHIP APPLICATION

Name of Company:
Address:
City: State: ZIP:
Phone: FAX: # of Employees:
Business Category:
Business Reference:
Business Reference:
Name of Company Representative to BEX:
Position:
Home Address:
City: State: ZIP:
Home Phone:
Name of Alternate Representative:
Position:
Home Address:
City: State: ZIP:
Home Phone:

We hereby make application for membership in the Business Executive Exchange (BEX) and, if accepted, agree to comply with all requirements.

Enclosed is (check one):

____ a check for the first quarter's dues
____ a check for the first year's dues

Make check payable to Business Executive Exchange. Please contact the BEX Treasurer to determine your pro-rated dues.

Signed: Date:

Return completed application and check to the BEX Treasurer.