Membership Application

About you:

First Name:   Last: 

Full Formal Name:

Current Job Title: 

Birthday (mm/dd):   Spouse/Partner/Significant Other:

About the organization you lead:

Company: 

Address:  

City:   State:   Zip: 

Workforce Size:  — Please Select — Small: 10 to 99 employees  Medium: 100 to 999 employees  Large: 1000 or more employees      Number of Employees: 

Description of Business: 

Website: 

Your contact info:

email: 

Office – Direct Phone:   Mobile: 

Executive Assistant (optional):

    Name: 

    email:   Phone: 

Preferred way for members to contact you:  — Please Select —  send email  call office  call mobile  text mobile  call assistant  email assistant 

Member Agreement:

I have read and agree to abide by the Rhode Island CEO Council's Membership Principles:

  eSignature:

I have read and agree to abide by the Rhode Island CEO Council's Membership Agreement:

  eSignature:

New Member Enrollment Fee:

Enrollment Fee: $1,800

Membership Dues:

Accel-Level: $400/month additional dues (1st CEO Board meeting prepaid with application)

Nonprofit Grant Request (501c3 status verified before processing payment)

Grant pays $600 of the Enrollment fee, $50/month (or $600/year) of Engage-level membership dues, and $150/month (or $1,800/year) of the additional Accel-level membership dues.

Payment Amount:

Initial Enrollment & Dues Payment: $ (payment processed with your membership application)
    Recurring Engage Monthly Dues: $ (begins after attending your first CEO Council event)
    Additional Accel Monthly Dues:    $ (begins after attending your first CEO Board meeting)

Payment Information:

Credit Card Type: Visa   MasterCard   American Express   or Pay by Check

Name:

exactly as it appears on the credit card

Credit Card Number:

Exp. (MM/YY): Code: (3 or 4 digit security code)

Billing Address:

Address:  

City:   State:   Zip: 

email:   Phone: 

Authorization to Charge your Credit Card:

By submitting this form, I authorize the Rhode Island CEO Council to charge this credit card according to the terms outlined above. This payment authorization is only for my member enrollment fee and my monthly or annual membership dues in the amount indicated above. I hereby certify that I am an authorized user of this credit card and that I will not dispute the payment with the credit card company so long as the initial dues and the future recurring month dues transaction amounts correspond to the above terms and the amounts specified in the "Payment Amount" section.

I have read and accordingly authorize payment as specified above.

  eSignature:

Invoice Request:

Click here to request an invoice for your records

Message:

 Note: 

Security:

When you click "Submit" your membership application will be sent to us
and you will be taken to the "Membership Payment" form.
Your payment must be completed before your membership can be activated.