NEVADA BUSINESS CONNECTIONS
CAPITAL REGION
1818 East College Parkway, Suite 100, Carson City, NV 89706
cell 775.771.5747
email [email protected]
Kris Holt, Executive Director
APPLICATION FOR MEMBERSHIP
Full Name:
Last
First
Title:
Company:
Physical
Address:
Street Address
Suite #
City
State
ZIP Code
Mailing
Address:
Street Address
Suite #
City
State
Extension:
Work Phone:
(
)
Home Phone:
(
)
Cell Phone:
Fax:
(
)
Email:
Business Type:
ZIP Code
(
)
(Enter up to 2 types, such as Contractor, Developer, Real Estate, Financial Services, etc.)
1.
2.
Membership Level: (Mark one)
Corporate Level ($1,200 annually)
To charge your credit card (MasterCard, VISA, American Express
or Discover), please supply the following information:
Card Number:
______ ______ ______ ______ Security Code: _______
Exp Date:
Regular Member Level ($160 annually)
_______ /_______
Billing Zip: __________
Print Name: _____________________________________
(As it appears on the credit card)
Signature:
Date:
Tax ID# 77-0720901
Make check payable to: Nevada Business Connections
Please complete the above NBC Membership Application and return it with your membership fee to:
Nevada Business Connections
1818 E. College Parkway, Suite 100
Carson City, NV 89706
For Office Use Only
DtRcvd:
AmtRcvd:
Ch#: