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Membership Information

You have selected the New Member Application membership level.

The price for membership is $50.00 now.

Do you have a discount code?

Account Information

Username

Password

Confirm Password

First Name

Last Name

Email Address

Confirm Email Address

Full Name LEAVE THIS BLANK

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About You

How would you like your name to appear on your name badge?

Birth Month and Day

Please upload your headshot for use in the EWPB online member directory.

Recommended size is 400px X 400px

Professional Information

Organization/Company Name

Position Title

Position Details

Briefly describe your current position.

Company Website

i.e. https://www.myurl.com

Preferred Address

i.e. Street Address, City, State, Postal Code

Preferred Email

Preferred Phone

i.e. 999-999-9999

Will you allow text messages to be sent to this number?

Yes

Is your preferred contact info your home or business?

Business

Home

LinkedIn Profile URL

i.e. https://www.linkedin.com/in/your-name-728936287/

Please indicate what industry your primary business falls under:

Hold Ctrl key to select more than one option.

Community Service Engagement

Please list at least one organization you currently volunteer with and indicate your role in each.

Volunteer Organization Name 1

Timeframe of Your Service

Volunteer Organization 1
i.e. 2012-2015

Your Role

Volunteer Organization 1
Describe your volunteer and/or leadership role (committee, board, volunteer, etc.)

Volunteer Organization Name 2

Timeframe of Your Service

Volunteer Organization 2
i.e. 2012-2015

Your Role

Volunteer Organization 2
Describe your volunteer and/or leadership role (committee, board, volunteer, etc.)

Volunteer Organization 3

Timeframe of Your Service

Volunteer Organization 3
i.e. 2012-2015

Your Role

Volunteer Organization 3
Describe your volunteer and/or leadership role (committee, board, volunteer, etc.)

Volunteer Organization 4

Timeframe of Your Service

Volunteer Organization 4
i.e. 2012-2015

Your Role

Volunteer Organization 4
Describe your volunteer and/or leadership role (committee, board, volunteer, etc.)

Additional Application Information

Share Your Resume

Only visible by other members.

Do you currently have an EWPB Member Mentor/Sponsor?

Yes

If you have a EWPB Member Mentor/Sponsor please include their Full Name.

Please indicate the EWPB event(s) you have attended or plan to attend.

Why do you want to join EWPB?

Any additional comments you would like to share?

Billing Address

First Name

Last Name

Address 1

Address 2

City

State

Postal Code

Country

Phone

Payment Information

Card Number

Expiration Date

Security Code (CVC)

Discount Code

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