Membership Application

   

Membership Application

Annual membership is an investment of $350.

To our supreme, sublime and awesome sisters working, playing and living life large outside of the Washington, DC metropolitan region, we have heard your pleas to bring a Success in the City Chapter to a city near you. We are working hard to make this happen! If you believe that you and your city are ready to take on the world with style, sass and panache, please email us and tell us all about you and why your city is ready for a Success in the City Chapter.
Most fields are optional. For example, if you would like periodic email updates, then provide an email and indicate your areas of interest. If you want us to contact you directly, then provide your name plus a phone or email.
A few fields are required, we marked them with a *

Your Information

* First Name Middle * Last
  Check this box if you are a member of the media

Login Information

* Username * Password * Confirm Password
Note: Your username can be your email, or another preferred internet login.
Your password should be at least 7 characters long and should not resemble or contain your login name.

Address and Contact Information

* Address
* City * State
* Zip
Country
Preferred Phone Best Time to Call
Home Phone Office Phone Mobile Phone
Fax
* Email
* Confirm Email

Organization Information

*Organization
Title
Address
City State
Zip
Country
Main Phone Toll-free Fax
Website
Please tell us more about yourself.
  Check this box if you prefer email in HTML format
 
Type the letters and numbers you see in the image: