Member - #MICRONET

Business Information

Company Name: *

Leave Blank:

Phone: *

Website:

Email: *

Business Description (200 char max):

Directory Category:

Employees:

Full-time Part-time

Comments / Questions:

Type of Business:

Physical Address

Line 1: *

Line 2:

City: *

State: *

Postal Code: *

Country: *

Mailing Address

Same as physical address

Line 1:

Line 2:

City:

State:

Postal Code:

Country:

Social Networking:

LinkedIn Facebook Twitter Instagram

Primary Contact Information

First Name: *

Last Name: *

Title:

Phone: *

Email: *

Contact Preference:

Email Phone

Password: *

Address

Same as Member Address

Line 1: *

Line 2

City: *

State: *

Postal Code: *

Country: *

Billing Contact Information

Same as Primary Contact

First Name: *

Last Name: *

Title:

Phone: *

Email: *

Contact Preference:

Email Phone

Password: *

Address

Same as Member Address

Line 1: *

Line 2

City: *

State: *

Postal Code: *

Country: *

Membership Options

Membership Package: *

Business with 0-5 Employees: $200.00
Business with 6-12 Employees: $275.00
Business with 13-20 Employees: $325.00
Business with 21-30 Employees: $375.00
Business with 31+ Employees: $450.00
Associate/Non-Profit: $150.00
Platinum Member: $800.00

Payment Option:

Bill me Charge my credit or debit card

Print Application

Member Application

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