Company Name:_________________________________________________

Contact Person: ___________________________

Phone: _______________________

Mailing Address:________________________________________________________

E-Mail: ___________________________________

Fax: _________________________

Business Category:_______________________________________________________

Description of your business for introduction in the Nokesville Biz newsletter.

_____________________________________________________________________________________________________________________________________________________________________________

In what ways would you like the NBA to help you in your business?

____________________________________________________________________________________________________________________________________________________________________________

If you select our Platinum Membership, would you host a NBA Network Social?

Network Socials are intended to promote your business. If you answer no to hosting a Network Social, would you attend a Network Social?

__________________________________________________________________________________________________________________________________________________________________________

Membership Package Deals:

r $199 Platinum Membership (over a $224 value)

r $109 Gold Membership ($128 value)

r $79 Silver Membership ($89 value)

r $39 Bronze Membership

r $25 Associate Membership (AM) - AM may not hold office or vote

Agreed to: ______________________________Date: _________ 

Received by: _____________________