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About
Members
Events
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Membership Application

Please fill out the required information below and our leadership will reach out to you soon.

"*" indicates required fields

Company Information

Legal Name of Company*

Operating Name (if different)

Company Address*

Street Address City Postal

Telephone*

Cell

Fax

Website

Years in Business*

Select One*

Sole Proprietorship

Corporation

Partnership

Business Category*

Number of Employees*

What percentage of total business does the above business category represent?*

Briefly Describe Your Company and the Services You Provide*

List other associations, clubs, organizations etc that your business is currently a member of and what positions are held

Professional Licenses / Affiliations

Member Information

Member's Name*

Years with Company*

Position with Company*

Email*

Cell Phone*

Alternate’s Name*

Years with Company*

Position with Company*

Email*

Cell Phone*

Reference Information

Please list three references (at least two should be business references)

Name*

Company*

Email*

Telephone*

Name*

Company*

Email*

Telephone*

Name*

Company*

Email*

Telephone*

Sponsor Information

Your sponsor is the current member who has invited you to the group and is sponsoring your membership

Sponsor Name*

Sponsor Company*

Agreement*

I agree*

Upon Acceptance of my application, I agree to have the amount of $125 +HST per month withdrawn monthly from my bank account (Direct Deposit information attached). I certify that all the information listed is accurate to the best of my knowledge.

Consent

I agree to receive future communications from London Referral Network

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