Referral Group Application

Please provide all information requested, including your personal and business biographies and two qualified professional references. Payment will be processed upon acceptance. For more detailed information, refer to the bylaws or call Jeremy Raley at (409) 838-6581.

Date

Format: M/d/yy

Name

First Name *

Last Name *

Title

Birthday (Month/Day)

Business Name

Business Address

Address Line 1

Address Line 2

City

Zip/Postal Code

Business Phone

Mobile Phone

Business Website

Which chair are you applying for:

Preferred Referral Group *

Tuesday Group Thursday Group First Available Chair

Provide a brief description of your product or services:

Personal/Business Biography (100 words or less):

Professional Business References (TWO required):

Name:

Relationship:

Phone Number

Name:

Relationship:

Phone Number

By submitting this application, I acknowledge that I have received and agree to adhere to the by-laws of the GBCOC Referral Group and give permission for the GBCOC to include my email address on their website.

Annual Investment: $120.00 per person/group (The $120 charge will apply to each group attended by your company.) And will be prorated for the first year of membership based on actual start date.

One time Application fee: $30.00 Fees will be billed once applicant is approved by Referral Group leadership committee.

Referral Group Application

Our purpose is to grow the economy, help businesses succeed, and have a positive impact.