Application for XPX Connecticut Individual Membership

New Member Information:

Please complete all the information in the following form and then press the Submit Application button at the bottom, where you will verify your information and provide payment via Credit Card.

Annual Individual Membership fee is $350.00

Applicant Information
Passcode*
(please enter a code, up to 10 characters, that you can remember to identify this application later)
First Name*
Last Name*
Company*
Corporate XPX ID
Website (http://sitename.com)
Contact Information
Address
Address 2
City
State
Zipcode
Phone
Cell Phone
Fax
Home Phone
Email
Billing Information
Billing Address
Billing Address 2
Billing City
Billing State
Billing Zipcode
Sponsor Information
Sponsor 1 Name
Sponsor 1 Email
Sponsor 1 Phone
Sponsor 2 Name
Sponsor 2 Email
Sponsor 2 P{hone
Your Resume
Select your Business Category
Years in this Company
Years in this Discipline
Describe your Products and Services (be specific)
Describe your Prior Experience (be specific)
Describe Client Engagements or Relevant Intellectual Property you have created (be specific)
Describe Professional Affiliations and Certifications (be specific)
Describe how you use your Knowledge and Experience to help business owners achieve a well-prepared and successful exit
Privacy
Upon membership approval, may we list you as a member and display your contact information in the XPX Boston membership directory?
CONSENT, AUTHORIZATION & WAIVER

I am interested in becoming a member of Exit Planning Exchange (XPX). I understand that the purpose of the organization is to build a strong, active consortium of experienced specialists. Members work independently and/or collectively in fields that enable business owners to successfully plan and execute activities to build and exit their businesses. I understand that membership is a privilege and agree to adhere to XPX’s membership criteria and high quality standards.

I hereby authorize XPX to contact the sponsors I have provided and/or any other person or organization having knowledge of me or my business in connection with my application for membership.

Further, I authorize said persons and/or organizations to respond and provide opinions and information. I hold said persons and/or organizations blameless and without liability for statements and opinions made regarding me, my business, my character, general reputation, experience or qualifications.

I certify that the information contained in this application is true and correct and that any misrepresentation shall be cause for denial of further consideration.