Application for XPX Boston Corporate 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 Corporate Membership fee is $900.00. All individual memberships associated with the corporate membership expire 12-calendar months after the corporate application is submitted.

Applicant Information
Passcode*
(please enter a code, up to 10 characters, that you can remember to identify this application later)
Company
Contact First Name*
Contact Last Name*
Website (http://sitename.com)
Mailing Information
Address
Address 2
City
State
Zipcode
Phone
Fax
Email
Billing Information
Billing Address
Billing Address 2
Billing City
Billing State
Billing Zipcode
Privacy
OK to display website?
OK to dispay email?
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 on our Corporate Individual Membership Applications and/or any other person or organization having knowledge of our business in connection with our 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.