Name :

Email :

DATE OF THE APPLICATION:

PARTIES OF THE AGREEMENT:

New Member Returning Member Transfer
Other, please explain:

Leads Club Inc. DBA
Women’s Division Men’s Division Coed Division

Please add me to the New Member Email List so I may receive valuable information on my membership and how to leverage my membership in Leads Club.

I AGREE TO ADHERE TO THE FOLLOWING:

1. Actively participate in promotionals weekly and a minimum of five 10 minute promotionals during any 12 month period. Provide sufficient number of business cards for the other members and the chapter business card file. Use my best efforts to generate leads and referrals for the other members. Adhere to all policies in the Member Handbook and be of good morale character.

2. Attendance Policy: No more than 12 absences in a 12 month period.

3. Forfeiture of membership: Violations of attendance policy; delinquent fees (delinqency occurs at end of second meeting of the month); Representing or promoting anything other than the ONE business listed on Member Application during weekly programs; Unethical business practices.

4. Application is not complete unless International Headquarters approves and accepts application. LEADS CLUB reserves the right to revoke this agreement at any time member's actions are deemed detrimental to the chapter's ability to exchange and generate quality leads and referrals, or adversely affect the dynamics of the chapter's ability to function within the system.

5. All fees are non-refundable. Membership is not transferable.

*By checking this box I hereby certify that I am agreeing to all the terms and conditions stated above and that the Chapter's current Director and I have discussed my category and find no conflicts within the Chapter.

*New Member Name (Electronic Signature)

*Date:

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*REQUIRED FIELDS

*BUSINESS CATEGORY

*CHAPTER NAME

*CHAPTER CITY *STATE

Your Regional Office: Australia Arizona Cen. Coast Cal Los Angeles Orange County No. Cal Inland Empire Riverside San Diego Colorado Florida Georgia Illinois Indiana Maryland/Wash. DC Oregon Texas

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*NAME

*BUSINESS NAME

*BUSINESS ADDRESS *HOME ADDRESS (Check One)

*Mailing Address

*CITY *STATE *ZIP

*DAY PHONE:

FAX

BIRTHDATE

*E-MAIL

*PLEASE DESCRIBE THE NATURE OF YOUR ONE BUSINESS / SERVICE LISTED ABOVE

Please fill out this questionnaire. This information will be kept confidential between chapter management team and office. Thank you.

*Is your business a:

Sole Proprietorship Partnership

Corporation Non-Profit Corporation

*Your position with this business is:

Owner Partner Sales

Corporate Officer Independent Distributor Manager

*Do you work your business full time? Yes No

*Length of time in business:

Does your business require: (Check those you presently possess).

Licensing (give registration number):

Certification (give title):

Accreditation (give title):

State or other board exams (give title):

Continuing education (state frequency nec.):

Bonding (Bonding Company Name):

Other (specify):

With what other businesses are you presently connected?

Do you presently have membership in a networking organization? Yes No

If yes, list names of organization(s):

REFERENCES: Please give names and phone numbers of clients/business associates we may contact.

Name Phone

Name Phone

Name Phone

©2008 ALI LASSEN