Corporate Membership Registration

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Person *

First Name

Last Name

Phone *

(###)

###

####

Tell Us About Your Ideal/Target Customer (B2B or B2C)

Gender Select all that apply

Male

Female

Both

Age

Select all that apply

16-25

25-40

40-60

60 and over

Workforce Status

Select all that apply

Founder/Owner

C Suite

Manager

Entry Level Professional

Support Staff

College Student

Homemaker

Retiree

What is the average annual gross revenue of your target customer

Select all that apply

Up to $100,000

Between $100,000 and $500,000

Between $500,000 and $1 Million

Over $1 Million

Why did you become a member of Black Connect? *

Select all that apply

To Support the Cause

Sponsorship/Partnership Opportunities

Generate Leads

Advertise Products & Services

Recruit Employees/Interns

Find Suppliers

Networking

Sell Products & Services

Find Investment Opportunities

Volunteering

Mentor Business Owners & Professionals