MembApp 071004

1. You Must Indicate Your Agreement to Make These Payments.

2. Option A: Authorize Charges to Your Credit Card.

3. Please Sign Below to Authorize These Charges:

Visa MasterCard American Express Discover

Credit card number Exp. Date

Print cardholder’s name as it appears on the card

Address that the credit card is billed to (required for approval of charges):

Signature of Cardholder or Bank Account Owner

This membership may be cancelled at any time by notifying eWomenNetwork, Inc. in writing.

You pay a one-time, lifetime initiation fee of $290, (non-refundable) and a monthly membership fee of only $16.95 (beginning the month following your enrollment).

IMPORTANT NOTE: This is your application only. Within five working days of receiving this application, eWomenNetwork will email you a receipt and complete information about your membership, including your Sign-In Name and Password, plus instructions for creating your online profile.

I agree to pay a one-time, nonrefundable, lifetime initiation fee of $290.00 and to pay $16.95 per month to remain an active member. My credit card or electronic check authorization supplied below will pay for these charges.

Your Membership Investment in eWomenNetwork:

Today’s Date:

*Applicant’s Name:

Company Name: Title:

*Day Phone: Evening Phone:

Street Address:

City: State: Zip:

*Email Address:

*Required Fields

Receive: 1. Your profile on the eWomenNetwork.com Web site 2. Unlimited access to the members profile database 3. Member discounts on events, products and services 4. Two personal, one-on-one coaching sessions with a premier

certified business coach 5. Access to the #1 networking program, “Increase Your Net Worth

by Developing Your Network” 6. Access to “members only” online networking forum and events

Instructions:Please pay your $290 initiation fee by electronic check or credit card by filling out and fax this completed form to

Your $16.95 monthly membership fees must be paid either by credit card or by electronic check on a U.S. bank account.

For questions about the application process, phone

For office use only.

Chpt Code

MD ID

SP

MM

2. Option B: Authorize Electronic Checks on Your U.S. Bank Account.

Business Checking Checking Savings

Bank Name as it appears on the check

Routing Number (9 digits) Account Number

866-493-3230.

314-968-9664 ext. 1

Donna Gamache

St. Louis