BLACKSONVILLE .COMmunity .NETwork
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Membership Application Blacksonville, LLC, subsidiaries, and affiliates Corporate Office: 1717 Shoreview Dr. Corner Suite Jacksonville, FL 32218 www.blacksonville.com 904-764-7828 office | 866-899-4886 fax
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EC NP MBE REF MISC
Business Membership: $500 Annual / $75 Per Month Non-Profit/MBE/ Black Expo/Chamber Member Discount Only: $300 Annual A Separate $100 Non-Refundable Set Up Fee is Required
If you choose the bank draft option, your account will be drafted between the 1st and 15th of the month
AFFILIATE USE ONLY
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NC
administered by Blacksonville .COMmunity .NETwork
Member Profile Effective Member Date:
Office Use Only
Assigned Affiliate Number __________________________________________ Associate Name __________________________________________________ Associate SSN Number (if Licensed) __________________________________ Associate License Number (In Florida/GA) ______________________________ Business Phone ___________________________________________________ Signature of Associate______________________________________________
Federal Tax ID Number _____________________________
Year Established ________________________ Type of Business ________________________
Business Name ___________________________________
Minority Certified ________ If yes, please list type of certification _________________________
Address _________________________________________
Number of Employees _______________ State this business is organized in _______________
_________________________________________________ City
State
Zip+4
Email Address ____________________________________ I do not wish to receive email updates from BCN about my Membership. (Your privacy is a priority with us! BCN will not sell your email address or personal information of any kind to third party vendors without prior consent.) Business Phone ___________________________________ Alternate Phone ___________________________________ Website/URL: _____________________________________ Authorized Users At least one authorized user must be in a position to legally bind the Covered Business Entity. The business owner must be listed here if he/she wishes to use plan benefits.
_________________________________________________ Last First MI Title
_________________________________________________ Last First MI Title
Payment Information -
Is stock of the business publicly traded?
Is this a FOR PROFIT or NON PROFIT business? • •
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Coupon Activation _________
Other _____________________________
Applicant: I understand that a written contract will be emailed within 24 hours that sets forth the terms of my membership, including any exclusions or limitations and I agree to be bound by the same. I further understand that the company will provide a copy of the final signed contract to me directly at the address noted herein or by email within the next fourteen days. If I have not received my contract within 14 days, I understand that it is my responsibility to call the Blacksonville Membership Dept. at 1-800-863-9130 or my account rep directly to obtain a copy. The signed contract, together with this application and the company Terms (see www.blacksonville.com), constitutes the entire agreement between the company and the member with respect to the membership, and there are no agreements, understandings, warranties or representations other than as set forth herein and in the membership contract. If I fail to pay my monthly membership fee on time, Blacksonville, LLC may suspend, retain, or cancel my domain account at any time. In Florida/Georgia, any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any materially false, incomplete, or misleading information concerning a material fact is guilty of a felony of the 3rd degree. Authorized Signature
X_____________________________________________________
Annual Bank Draft
Authorization for Electronic Transfers Drawn by and Payable for Membership: I hereby authorize Blacksonville, LLC to charge/draft my checking/savings account from the Financial Institution listed below. This authority is to remain in effect for successive (1 year) terms unless either party notifies the other in writing to the contrary within at least (60) days prior to expiration of the current term. A $100 Deactivation Service Fee will be billed for Account Cancellations/Delinquencies after 60 days from signature with no written notice. Your account will be drafted each month on or about the effective date of your membership. Name of Bank ____________________________
Acct: #____________________________________
Bank Address ____________________________
Sig. of Acct Holder X ________________________
*
NO
I certify that this FOR PROFIT or NON-PROFIT business is a legal entity. I realize non-legal entities are not covered by this plan.
Monthly Bank Draft
____________________________ City State Zip
YES
Checking Account Savings Account (attach voided check from account to be drafted.)
Monthly or Annual Payment by Credit Card
Please fill out for Bank Draft or Credit Card Payment options: Monthly/Annual draft charge amount. Your credit card charge will serve as your receipt. Membership Draft Amount $ Total deposit enclosed by check, money order, cash or charge to credit card
(If paying by credit card an additional $3 fee will be debited per transaction )
Annual Direct Bill
I wish to pay by credit card unless I revoke this authorization in writing. I realize my account will st th be charged on or between the 1 or 15 monthly.
I wish to pay annually by check. Checks or money orders should be made payable to Blacksonville, LLC
Card #:___________________________________________ Exp. Date: __________(Mo./Yr.) Amount Enclosed: ________________________________ Cardholder Signature: X___________________________________ MC
VI
DS
AX
Membership Application (2.1) | 2008 Blacksonville, LLC White copy: Home Office – Jacksonville, FL Yellow copy: Marketing Consultant
Pink copy: Member