2018 Annual Membership Application and Invoice

2018 Annual Membership Application and Invoice

Single Agency Membership Fee (one location): $55.00 per calendar year

Corporate Agency Membership Fee: $100.00 per calendar year*(multiple locations/businesses) If’d please fill out page 2

Agency Name: ______(Agency will be printed exactly as it appears here)

Agency Address: ______City: ______Zip:______

Agency Phone: ______Agency Fax: ______County: ______

Agency Website: ______Not-for-Profit For Profit

Agency Director/CEO:______

Agency Description:  Healthcare  Senior Living Facility/Community  Products & Services  Resource Agency

 Transportation  Financial Services  Insurance Services  Media & Promotion  Restaurant

Primary Contact Name: ______Title: ______

Primary Contact Address:  Same as above  Other: ______

Primary Contact Phone: ______Fax: ______

Email: ______Preferred Communication:  Email  Mail

Secondary Contact Name: ______Title: ______

Secondary Contact Address:  Same as above  Other: ______

Secondary Contact Phone: ______Fax: ______

Email: ______Preferred Communication:  Email  Mail

What percent of your business serves seniors? ______

What is your main reason for joining SMG? ______

Please provide 2 professional references (business names that you have worked with) to verify your agency:

Name: ______Phone: ______

Name: ______Phone: ______

Please send completed application and check to: Senior Marketing Group P.O. Box 1344 Holland, MI 49422-1344 Please make checks payable to: Senior Marketing Group-The Lakeshore Area

Payments for Membership Dues are required by March 31, 2018 to be considered in good-standing

Signature: ______Date of Application ______

Questions? Please contact: Cathy Blackburn @616.550.4367

The Senior Marketing Group is dedicated to improving the quality of life of seniors by working together as marketing professionals in the lakeshore area.

1/2018

Page 2

*Corporate Membership Attachment

2018 Annual Membership Application and Invoice

Agency #2:

Agency Name: ______(Agency will be printed exactly as it appears here)

Agency Address: ______City: ______Zip:______

Agency Phone: ______Agency Contact Name: ______

Contact Number: ______Contact Email: ______

Agency Description:  Healthcare  Senior Living Facility/Community  Products & Services  Resource Agency

 Transportation  Financial Services  Insurance Services  Media & Promotion  Restaurant

Agency #3:

Agency Name: ______(Agency will be printed exactly as it appears here)

Agency Address: ______City: ______Zip:______

Agency Phone: ______Agency Contact Name: ______

Contact Number: ______Contact Email: ______

Agency Description:  Healthcare  Senior Living Facility/Community  Products & Services  Resource Agency

 Transportation  Financial Services  Insurance Services  Media & Promotion  Restaurant

Agency #4:

Agency Name: ______(Agency will be printed exactly as it appears here)

Agency Address: ______City: ______Zip:______

Agency Phone: ______Agency Contact Name: ______

Contact Number: ______Contact Email: ______

Agency Description:  Healthcare  Senior Living Facility/Community  Products & Services  Resource Agency

 Transportation  Financial Services  Insurance Services  Media & Promotion  Restaurant

Agency #5:

Agency Name: ______(Agency will be printed exactly as it appears here)

Agency Address: ______City: ______Zip:______

Agency Phone: ______Agency Contact Name: ______

Contact Number: ______Contact Email: ______

Agency Description:  Healthcare  Senior Living Facility/Community  Products & Services  Resource Agency

 Transportation  Financial Services  Insurance Services  Media & Promotion  Restaurant

The Senior Marketing Group is dedicated to improving the quality of life of seniors by working together as marketing professionals in the lakeshore area.

1/2018