Company: ___________________________________________________

Address: ____________________________________________________

City / State / Zip: ______________________ _____ ________________

Profession / Business: __________________________________________

Work Phone: (___) ____ - ______ Home Phone: (___) ____ - ______

Work Fax: (___) ____ - ______ Alternate Phone: (___) ____ - ______

E-mail: _______________________ Web Site: _____________________

Length of time working in current profession / business: _____ years

Professional designations/awards: ____________________________

Ideal Lead for you: __________________________________________

Other affiliations/memberships (including other network groups):

1._________________________ 2._________________________
3._________________________ 4._________________________

Professions / businesses most likely to refer leads to (see attached list):

1._________________________ 2._________________________
3._________________________ 4._________________________

Professions / businesses most likely to receive leads from (see attached list):

1._________________________ 2.________________________
3._________________________ 4.________________________

Sponsor #1:_______________ Sponsor #2:_________________ Date: _______

(Last updated: 10/1/99)