Member

Business Information

Company Name: *

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Phone: *

Website: *

Email:

Business Description (200 char max):

Directory Category: *

Year Founded: *

Twitter ID:

Facebook ID:

Physical Address

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Line 2:

City: *

State: *

Postal Code: *

Country: *

Social Networking:

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Primary Contact Information

First Name: *

Last Name: *

Title: *

Phone: *

Cell Phone: *

Fax:

Email: *

Contact Preference:

Email Phone

Login: *

Password: *

Address

Same as Member Address

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Line 2

City: *

State: *

Postal Code: *

Country: *

Membership Options

Membership Package: *

Circle of Influence Membership: $1,400.00
-Get Your Feet Wet- Includes tickets to 4 major events, After Darks and Newsmaker Connections. Business Leaders Membership: $1,950.00
-Have a Seat at the Table- Includes a ticket to every event that VICA holds in your membership year. Bronze Circle of Influence: $3,000.00
Customizable Package - Please contact the VICA Office in order to customize your package. Silver Circle of Influence : $6,000.00
Customizable Package - Please contact the VICA Office in order to customize your package. Gold Circle of Influence : $9,000.00
Customizable Package - Please contact the VICA Office in order to customize your package. Platinum Circle of Influence: $12,000.00
Customizable Package - Please contact the VICA Office in order to customize your package. Premier Partner: $17,000.00
Customizable Package - Please contact the VICA Office in order to customize your package. President's Circle: $27,000.00
Customizable Package - Please contact the VICA Office in order to customize your package. The President's Circle is for any membership $27,000 - $39,000. Small Business Introductory Membership: $850.00
Base Membership for One Representative

Payment Option:

Bill me Charge my credit or debit card

Member Application

Address