Member Application

Welcome and thank you for applying to be a member/investor in Greater Fort Wayne Inc. All membership applications are subject to approval. For additional information or to discuss investor benefits please contact Investor Relations at 260 420-6945.

Business Information

Company Name: *

Phone: *

Website: *

Email:

Business Description (200 char max):

Directory Category: *

Employees: *

Full-time Part-time

Business Keywords (enter a space between words):

Comments / Questions:

ReferredBy:

Company's Fiscal Month : *

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

Primary Contact Information

First Name: *

Last Name: *

Phone: *

Cell Phone:

Fax:

Billing Contact Information

Same as Primary Contact

First Name: *

Last Name: *

Phone: *

Cell Phone:

Fax:

Membership Options

Membership Package: *

ATHENA International Fort Wayne Affiliate: $100.00
Investment Level 1: $400.00
1-10 Employees Investment Level 2: $600.00
11 -20 Employees Investment Level 3: $800.00
21-50 Employees Investment Level 4: $1,000.00
51-99 Employees Leadership Fort Wayne Alumni: $150.00

Payment Option:

Charge my credit or debit card

In the effort to fight spam, please provide the answer to the following question.

What is the sum of 10 plus 9?: *

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