Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Has your professional license ever been suspended or revoked?

Yes

No

Have you ever been a member of a networking and referral group before?

Yes

No

Are you willing and able to commit to attend weekly meetings, arrive on time, and actively participate in the group?

Yes

No

Please provide me with more information

Are you willing to send a substitute if you are unable to attend a meeting?

Yes

No

Have you ever been convicted of a felony?

Yes

No

At 605 Connections, we strive to pass one referral per week, have one 1-2-1 per week with another member, bring one visitor per month, miss a maximum of two meetings per 6-month period, and send a substitute for any missed meetings beyond those two. Are you able and willing to commit to trying to achieve those goals?

Yes

No

Please provide me with more information

Absolute minimum standards for members are to follow the attendance policy, to have passed at least 6 referrals in a calendar year, and to bring 2 visitors throughout the year. Are you willing to commit to these minimum standards?

Yes

No