New Member Application

Referred by:
First Last
Your Name*
First Middle Last Suffix
Nickname
Nickname
Upload Your Headshot*
Accepted file types: jpg, png.
Please add 3-5 informational sentences that we could use while highlighting you and your business. If this is left blank we will not have the information needed to announce your membership.
Your Address Information*
Street Address Address Line 2 City State ZIP Code
Home Phone
Business Phone
Mobile Phone*
Preferred Email*
T-Shirt Size*
Please let us know what T-Shirt size you would like.
Date of Birth*
Social Media
Instagram:
Personal Facebook:
Personal Facebook:
Business Facebook:
LinkedIn:
Employer or Business Information
Applicant Employer or Business*
Occupation or Title*
Employer or Business Address
Street Address Address Line 2 City State ZIP Code
Business Website
How long in present occupation?*
Send mail to?*
- Home
- Business
Briefly describe your business occupation.*
Do you have any future interest in serving on the Clayton W.I.N Board?*
- Yes
- No
Please list the dates of the events you attended:*
Date Format: MM slash DD slash YYYY

You must attend two (2) WIN events (one must be a general meeting). Event dates are listed on our website.
Date*
Date Format: MM slash DD slash YYYY
Accept*
- I have read and agree to the Bylaws and hereby request membership in Clayton W.I.N.
Clayton W.I.N. membership dues are $125 annually.
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