AMCF Associate Member Application

AMCF Associate Member Application
Date:
We will join under Service Provider at:
We will join under Academia / Nonprofit at:
Name of Firm:
Name of Partner or Officer submitting application:
Title:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number:

Area CodePhone Number
Fax Number:

Area CodePhone Number
E-mail:
Web Address:
Corporate Headquarters Address (IF DIFFERENT THAN ADDRESS ABOVE):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Has your organization previously been in business under any other name(s)?
(If Yes above, please give particulars on an additional sheet of paper).
Attach file here:

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If your organization is owned by individuals, or companies other than the firm's consulting staff, please list the major owner or owners of the firm.
Please attach brochures or similar material describing your organization and its services. Copies of sample promotional letters or other material used in new business development may also be included.
Attach file(s) here:

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As appropriate, on additional sheets please prepare a representative client list (a minimum of 5) served during the last three years. Indicate the type of service performed, when performed, and give the name and address of the client executive with whom you worked on the assignment.
Attach file(s) here:

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Has your organization or any subsidiary (operating under its present or any prior name) ever been the subject of a voluntary or involuntary petition for bankruptcy, assignment for the benefit of creditors, or similar proceeding?
(If Yes above, please attach a description of the proceeding and the final adjudication, name, and address of the court or other tribunal and relevant dates).
Attach file(s) here:

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My Products

Application Fee$350.00

Payment Method
Credit	Express

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Should be Empty:

AMCF Associate Member Application

My Products*

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