November 19, 2015 Info Membership Application Membership Application Step 1 of 4 - Personal Information 0% SalutationMrMrsMsDrRevName* First Last City of Residence*State of Residence*Cell Phone*Email* Company*Are you the owner / partner? Yes Position*Company Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Work PhoneCompany Website LinkedIn Profile Facebook TwitterSponsoring FUSION Member(s)*First NameLast Name Home Church*City of ChurchHow have you served in church?Christian Organization Affiliation(s)OrganizationRole Do you fully ascribe to the Christian Statement of Faith below?*I believe in Jesus Christ as my Lord and Savior and that the Bible is the inspired and infallible Word of God. I believe that there is one God, eternally existing in three persons— Father, Son, and Holy Spirit. I believe in the full humanity and deity of the Lord Jesus Christ, His virgin birth, His sinless life, His miracles, His vicarious and atoning death through His shed blood, His bodily resurrection, His ascension, and His personal return in power and glory and in the presence and power of the Holy Spirit.YesNoPlease Explain What is your profession? (check all that apply)* Accountant Attorney Banking & Finance Consulting & Services Financial Services Insurance Human Resources Investment Advisor Marketing Real Estate Other Other ProfessionAreas of specialtyDescribe the primary services you provide to clients.How many years have you been in your profession?How many years have you been in your current position?What is your primary geographic territory?How many years have you been working in your primary geographic territory?How many years of total work experience?College(s) Attended and Degree(s) EarnedSchoolDegreeMajor Current Certifications (check all that apply) CFA CFP CPA EA Other Other CertificationsFUSION members do business with each other's clients. Describe your typical client.Describe the last two referrals made to you:Example: A business consultant referred me to a client in need of an attorney for patenting. Describe the last two referrals you made to others:Example: I referred a client to a CPA to help him review his taxes. How do you glorify God through your business?What are your expectations for your FUSION Membership in terms of your spiritual walk?What are your expectations for your FUSION Membership in terms of your business?What are your expectations of your FUSION Membership in terms of your network relationships?How do you expect to contribute to FUSION members? (check all that apply) Referral to clients Introductions to resources or professionals Technical Resources Other Other ResourcesMedia Consent and Release*I understand that FUSION Leaders may record me (on video, film, photograph, or other medium) at various FUSION Leader events. I grant permission to FUSION Leaders to use such recordings for its marketing and promotional content, in whole or in part, without restrictions or limitations for any purposes that FUSION Leaders deems appropriate. I understand that I will receive no compensation for my appearance in any recordings or content. FUSION Leaders shall have complete ownership of such records and content. I have read and agree to the terms. Application Submission*By submitting this application, I agree to the collection, use and processing of the personal information I provide to FUSION in this membership application for the purposes of organization administration, payment of my dues, and inclusion of my contact information in a members' directory that will be distributed to members of FUSION. By my electronic signature below, I certify the information provided is true and correct, and agree to the terms expressed in this membership application. E-Signature/Type in Full Name to submit Submission Date This iframe contains the logic required to handle AJAX powered Gravity Forms.