Membership Application

<!-- Begin MailChimp Signup Form --><!-- [et_pb_line_break_holder] --><link href="//cdn-images.mailchimp.com/embedcode/classic-10_7.css" rel="stylesheet" type="text/css"><!-- [et_pb_line_break_holder] --><style type="text/css"><!-- [et_pb_line_break_holder] --> #mc_embed_signup{background:#fff; clear:left; font:14px Helvetica,Arial,sans-serif; }<!-- [et_pb_line_break_holder] --> /* Add your own MailChimp form style overrides in your site stylesheet or in this style block.<!-- [et_pb_line_break_holder] --> We recommend moving this block and the preceding CSS link to the HEAD of your HTML file. */<!-- [et_pb_line_break_holder] --></style><!-- [et_pb_line_break_holder] --><div id="mc_embed_signup"><!-- [et_pb_line_break_holder] --><form action="https://infuzed.us3.list-manage.com/subscribe/post?u=2c48fc9d6bd8b12257b39e407&id=b4554be978" method="post" id="mc-embedded-subscribe-form" name="mc-embedded-subscribe-form" class="validate" target="_blank" novalidate><!-- [et_pb_line_break_holder] --> <div id="mc_embed_signup_scroll"><!-- [et_pb_line_break_holder] --> <h2>Subscribe to our mailing list</h2><!-- [et_pb_line_break_holder] --><div class="indicates-required"><span class="asterisk">*</span> indicates required</div><!-- [et_pb_line_break_holder] --><div class="mc-field-group"><!-- [et_pb_line_break_holder] --> <label for="mce-MMERGE6">Group I am registering for </label><!-- [et_pb_line_break_holder] --> <select name="MMERGE6" class="" id="mce-MMERGE6"><!-- [et_pb_line_break_holder] --> <option value=""></option><!-- [et_pb_line_break_holder] --> <option value="TAURANGA MA11">TAURANGA MA11</option><!-- [et_pb_line_break_holder] --><option value="MOUNT MA11">MOUNT MA11</option><!-- [et_pb_line_break_holder] --><option value="SMALL BUSINESS LEADERS">SMALL BUSINESS LEADERS</option><!-- [et_pb_line_break_holder] --><option value="BUSINESS LEADERS">BUSINESS LEADERS</option><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> </select><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div class="mc-field-group"><!-- [et_pb_line_break_holder] --> <label for="mce-FNAME">First Name <span class="asterisk">*</span><!-- [et_pb_line_break_holder] --></label><!-- [et_pb_line_break_holder] --> <input type="text" value="" name="FNAME" class="required" id="mce-FNAME"><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div class="mc-field-group"><!-- [et_pb_line_break_holder] --> <label for="mce-MMERGE13">Last Name <span class="asterisk">*</span><!-- [et_pb_line_break_holder] --></label><!-- [et_pb_line_break_holder] --> <input type="text" value="" name="MMERGE13" class="required" id="mce-MMERGE13"><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div class="mc-field-group"><!-- [et_pb_line_break_holder] --> <label for="mce-EMAIL">Email Address <span class="asterisk">*</span><!-- [et_pb_line_break_holder] --></label><!-- [et_pb_line_break_holder] --> <input type="email" value="" name="EMAIL" class="required email" id="mce-EMAIL"><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div class="mc-field-group size1of2"><!-- [et_pb_line_break_holder] --> <label for="mce-MMERGE14">Mobile <span class="asterisk">*</span><!-- [et_pb_line_break_holder] --></label><!-- [et_pb_line_break_holder] --> <input type="number" name="MMERGE14" class="required" value="" id="mce-MMERGE14"><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div class="mc-field-group"><!-- [et_pb_line_break_holder] --> <label for="mce-MMERGE12">Applicant 2 - First Name <span class="asterisk">*</span><!-- [et_pb_line_break_holder] --></label><!-- [et_pb_line_break_holder] --> <input type="text" value="" name="MMERGE12" class="required" id="mce-MMERGE12"><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div class="mc-field-group"><!-- [et_pb_line_break_holder] --> <label for="mce-LNAME">Last Name <span class="asterisk">*</span><!-- [et_pb_line_break_holder] --></label><!-- [et_pb_line_break_holder] --> <input type="text" value="" name="LNAME" class="required" id="mce-LNAME"><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div class="mc-field-group"><!-- [et_pb_line_break_holder] --> <label for="mce-MMERGE15">Email <span class="asterisk">*</span><!-- [et_pb_line_break_holder] --></label><!-- [et_pb_line_break_holder] --> <input type="text" value="" name="MMERGE15" class="required" id="mce-MMERGE15"><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div class="mc-field-group size1of2"><!-- [et_pb_line_break_holder] --> <label for="mce-MMERGE3">Mobile <span class="asterisk">*</span><!-- [et_pb_line_break_holder] --></label><!-- [et_pb_line_break_holder] --> <input type="number" name="MMERGE3" class="required" value="" id="mce-MMERGE3"><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div class="mc-address-group"><!-- [et_pb_line_break_holder] --> <div class="mc-field-group"><!-- [et_pb_line_break_holder] --> <label for="mce-MMERGE4-addr1">Address </label><!-- [et_pb_line_break_holder] --> <input type="text" value="" maxlength="70" name="MMERGE4[addr1]" id="mce-MMERGE4-addr1" class=""><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="mc-field-group"><!-- [et_pb_line_break_holder] --> <label for="mce-MMERGE4-addr2">Address Line 2</label><!-- [et_pb_line_break_holder] --> <input type="text" value="" maxlength="70" name="MMERGE4[addr2]" id="mce-MMERGE4-addr2"> <!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="mc-field-group size1of2"><!-- [et_pb_line_break_holder] --> <label for="mce-MMERGE4-city">City</label><!-- [et_pb_line_break_holder] --> <input type="text" value="" maxlength="40" name="MMERGE4[city]" id="mce-MMERGE4-city" class=""><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="mc-field-group size1of2"><!-- [et_pb_line_break_holder] --> <label for="mce-MMERGE4-state">State/Province/Region</label><!-- [et_pb_line_break_holder] --> <input type="text" value="" maxlength="20" name="MMERGE4[state]" id="mce-MMERGE4-state" class=""><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="mc-field-group size1of2"><!-- [et_pb_line_break_holder] --> <label for="mce-MMERGE4-zip">Postal / Zip Code</label><!-- [et_pb_line_break_holder] --> <input type="text" value="" maxlength="10" name="MMERGE4[zip]" id="mce-MMERGE4-zip" class=""><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="mc-field-group size1of2"><!-- [et_pb_line_break_holder] --> <label for="mce-MMERGE4-country">Country</label><!-- [et_pb_line_break_holder] --> <select name="MMERGE4[country]" id="mce-MMERGE4-country" class=""><option value="164">USA</option><option value="286">Aaland Islands</option><option value="274">Afghanistan</option><option value="2">Albania</option><option value="3">Algeria</option><option value="178">American Samoa</option><option value="4">Andorra</option><option value="5">Angola</option><option value="176">Anguilla</option><option value="175">Antigua And Barbuda</option><option value="6">Argentina</option><option value="7">Armenia</option><option value="179">Aruba</option><option value="8">Australia</option><option value="9">Austria</option><option value="10">Azerbaijan</option><option value="11">Bahamas</option><option value="12">Bahrain</option><option value="13">Bangladesh</option><option value="14">Barbados</option><option value="15">Belarus</option><option value="16">Belgium</option><option value="17">Belize</option><option value="18">Benin</option><option value="19">Bermuda</option><option value="20">Bhutan</option><option value="21">Bolivia</option><option value="325">Bonaire, Saint Eustatius and Saba</option><option value="22">Bosnia and Herzegovina</option><option value="23">Botswana</option><option value="181">Bouvet Island</option><option value="24">Brazil</option><option value="180">Brunei Darussalam</option><option value="25">Bulgaria</option><option value="26">Burkina Faso</option><option value="27">Burundi</option><option value="28">Cambodia</option><option value="29">Cameroon</option><option value="30">Canada</option><option value="31">Cape Verde</option><option value="32">Cayman Islands</option><option value="33">Central African Republic</option><option value="34">Chad</option><option value="35">Chile</option><option value="36">China</option><option value="185">Christmas Island</option><option value="37">Colombia</option><option value="204">Comoros</option><option value="38">Congo</option><option value="183">Cook Islands</option><option value="268">Costa Rica</option><option value="275">Cote D'Ivoire</option><option value="40">Croatia</option><option value="276">Cuba</option><option value="298">Curacao</option><option value="41">Cyprus</option><option value="42">Czech Republic</option><option value="318">Democratic Republic of the Congo</option><option value="43">Denmark</option><option value="44">Djibouti</option><option value="289">Dominica</option><option value="187">Dominican Republic</option><option value="45">Ecuador</option><option value="46">Egypt</option><option value="47">El Salvador</option><option value="48">Equatorial Guinea</option><option value="49">Eritrea</option><option value="50">Estonia</option><option value="51">Ethiopia</option><option value="189">Falkland Islands</option><option value="191">Faroe Islands</option><option value="52">Fiji</option><option value="53">Finland</option><option value="54">France</option><option value="193">French Guiana</option><option value="277">French Polynesia</option><option value="56">Gabon</option><option value="57">Gambia</option><option value="58">Georgia</option><option value="59">Germany</option><option value="60">Ghana</option><option value="194">Gibraltar</option><option value="61">Greece</option><option value="195">Greenland</option><option value="192">Grenada</option><option value="196">Guadeloupe</option><option value="62">Guam</option><option value="198">Guatemala</option><option value="270">Guernsey</option><option value="63">Guinea</option><option value="65">Guyana</option><option value="200">Haiti</option><option value="66">Honduras</option><option value="67">Hong Kong</option><option value="68">Hungary</option><option value="69">Iceland</option><option value="70">India</option><option value="71">Indonesia</option><option value="278">Iran</option><option value="279">Iraq</option><option value="74">Ireland</option><option value="323">Isle of Man</option><option value="75">Israel</option><option value="76">Italy</option><option value="202">Jamaica</option><option value="78">Japan</option><option value="288">Jersey (Channel Islands)</option><option value="79">Jordan</option><option value="80">Kazakhstan</option><option value="81">Kenya</option><option value="203">Kiribati</option><option value="82">Kuwait</option><option value="83">Kyrgyzstan</option><option value="84">Lao People's Democratic Republic</option><option value="85">Latvia</option><option value="86">Lebanon</option><option value="87">Lesotho</option><option value="88">Liberia</option><option value="281">Libya</option><option value="90">Liechtenstein</option><option value="91">Lithuania</option><option value="92">Luxembourg</option><option value="208">Macau</option><option value="93">Macedonia</option><option value="94">Madagascar</option><option value="95">Malawi</option><option value="96">Malaysia</option><option value="97">Maldives</option><option value="98">Mali</option><option value="99">Malta</option><option value="207">Marshall Islands</option><option value="210">Martinique</option><option value="100">Mauritania</option><option value="212">Mauritius</option><option value="241">Mayotte</option><option value="101">Mexico</option><option value="102">Moldova, Republic of</option><option value="103">Monaco</option><option value="104">Mongolia</option><option value="290">Montenegro</option><option value="294">Montserrat</option><option value="105">Morocco</option><option value="106">Mozambique</option><option value="242">Myanmar</option><option value="107">Namibia</option><option value="108">Nepal</option><option value="109">Netherlands</option><option value="110">Netherlands Antilles</option><option value="213">New Caledonia</option><option value="111" selected>New Zealand</option><option value="112">Nicaragua</option><option value="113">Niger</option><option value="114">Nigeria</option><option value="217">Niue</option><option value="214">Norfolk Island</option><option value="272">North Korea</option><option value="116">Norway</option><option value="117">Oman</option><option value="118">Pakistan</option><option value="222">Palau</option><option value="282">Palestine</option><option value="119">Panama</option><option value="219">Papua New Guinea</option><option value="120">Paraguay</option><option value="121">Peru</option><option value="122">Philippines</option><option value="221">Pitcairn</option><option value="123">Poland</option><option value="124">Portugal</option><option value="126">Qatar</option><option value="315">Republic of Kosovo</option><option value="127">Reunion</option><option value="128">Romania</option><option value="129">Russia</option><option value="130">Rwanda</option><option value="205">Saint Kitts and Nevis</option><option value="206">Saint Lucia</option><option value="324">Saint Martin</option><option value="237">Saint Vincent and the Grenadines</option><option value="132">Samoa (Independent)</option><option value="227">San Marino</option><option value="255">Sao Tome and Principe</option><option value="133">Saudi Arabia</option><option value="134">Senegal</option><option value="326">Serbia</option><option value="135">Seychelles</option><option value="136">Sierra Leone</option><option value="137">Singapore</option><option value="302">Sint Maarten</option><option value="138">Slovakia</option><option value="139">Slovenia</option><option value="223">Solomon Islands</option><option value="140">Somalia</option><option value="141">South Africa</option><option value="257">South Georgia and the South Sandwich Islands</option><option value="142">South Korea</option><option value="311">South Sudan</option><option value="143">Spain</option><option value="144">Sri Lanka</option><option value="293">Sudan</option><option value="146">Suriname</option><option value="225">Svalbard and Jan Mayen Islands</option><option value="147">Swaziland</option><option value="148">Sweden</option><option value="149">Switzerland</option><option value="285">Syria</option><option value="152">Taiwan</option><option value="260">Tajikistan</option><option value="153">Tanzania</option><option value="154">Thailand</option><option value="233">Timor-Leste</option><option value="155">Togo</option><option value="232">Tonga</option><option value="234">Trinidad and Tobago</option><option value="156">Tunisia</option><option value="157">Turkey</option><option value="158">Turkmenistan</option><option value="287">Turks & Caicos Islands</option><option value="159">Uganda</option><option value="161">Ukraine</option><option value="162">United Arab Emirates</option><option value="262">United Kingdom</option><option value="163">Uruguay</option><option value="165">Uzbekistan</option><option value="239">Vanuatu</option><option value="166">Vatican City State (Holy See)</option><option value="167">Venezuela</option><option value="168">Vietnam</option><option value="169">Virgin Islands (British)</option><option value="238">Virgin Islands (U.S.)</option><option value="188">Western Sahara</option><option value="170">Yemen</option><option value="173">Zambia</option><option value="174">Zimbabwe</option></select><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div class="mc-address-group"><!-- [et_pb_line_break_holder] --> <div class="mc-field-group"><!-- [et_pb_line_break_holder] --> <label for="mce-MMERGE16-addr1">Postal Address (if different from above) </label><!-- [et_pb_line_break_holder] --> <input type="text" value="" maxlength="70" name="MMERGE16[addr1]" id="mce-MMERGE16-addr1" class=""><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="mc-field-group"><!-- [et_pb_line_break_holder] --> <label for="mce-MMERGE16-addr2">Address Line 2</label><!-- [et_pb_line_break_holder] --> <input type="text" value="" maxlength="70" name="MMERGE16[addr2]" id="mce-MMERGE16-addr2"> <!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="mc-field-group size1of2"><!-- [et_pb_line_break_holder] --> <label for="mce-MMERGE16-city">City</label><!-- [et_pb_line_break_holder] --> <input type="text" value="" maxlength="40" name="MMERGE16[city]" id="mce-MMERGE16-city" class=""><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="mc-field-group size1of2"><!-- [et_pb_line_break_holder] --> <label for="mce-MMERGE16-state">State/Province/Region</label><!-- [et_pb_line_break_holder] --> <input type="text" value="" maxlength="20" name="MMERGE16[state]" id="mce-MMERGE16-state" class=""><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="mc-field-group size1of2"><!-- [et_pb_line_break_holder] --> <label for="mce-MMERGE16-zip">Postal / Zip Code</label><!-- [et_pb_line_break_holder] --> <input type="text" value="" maxlength="10" name="MMERGE16[zip]" id="mce-MMERGE16-zip" class=""><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="mc-field-group size1of2"><!-- [et_pb_line_break_holder] --> <label for="mce-MMERGE16-country">Country</label><!-- [et_pb_line_break_holder] --> <select name="MMERGE16[country]" id="mce-MMERGE16-country" class=""><option value="164">USA</option><option value="286">Aaland Islands</option><option value="274">Afghanistan</option><option value="2">Albania</option><option value="3">Algeria</option><option value="178">American Samoa</option><option value="4">Andorra</option><option value="5">Angola</option><option value="176">Anguilla</option><option value="175">Antigua And Barbuda</option><option value="6">Argentina</option><option value="7">Armenia</option><option value="179">Aruba</option><option value="8">Australia</option><option value="9">Austria</option><option value="10">Azerbaijan</option><option value="11">Bahamas</option><option value="12">Bahrain</option><option value="13">Bangladesh</option><option value="14">Barbados</option><option value="15">Belarus</option><option value="16">Belgium</option><option value="17">Belize</option><option value="18">Benin</option><option value="19">Bermuda</option><option value="20">Bhutan</option><option value="21">Bolivia</option><option value="325">Bonaire, Saint Eustatius and Saba</option><option value="22">Bosnia and Herzegovina</option><option value="23">Botswana</option><option value="181">Bouvet Island</option><option value="24">Brazil</option><option value="180">Brunei Darussalam</option><option value="25">Bulgaria</option><option value="26">Burkina Faso</option><option value="27">Burundi</option><option value="28">Cambodia</option><option value="29">Cameroon</option><option value="30">Canada</option><option value="31">Cape Verde</option><option value="32">Cayman Islands</option><option value="33">Central African Republic</option><option value="34">Chad</option><option value="35">Chile</option><option value="36">China</option><option value="185">Christmas Island</option><option value="37">Colombia</option><option value="204">Comoros</option><option value="38">Congo</option><option value="183">Cook Islands</option><option value="268">Costa Rica</option><option value="275">Cote D'Ivoire</option><option value="40">Croatia</option><option value="276">Cuba</option><option value="298">Curacao</option><option value="41">Cyprus</option><option value="42">Czech Republic</option><option value="318">Democratic Republic of the Congo</option><option value="43">Denmark</option><option value="44">Djibouti</option><option value="289">Dominica</option><option value="187">Dominican Republic</option><option value="45">Ecuador</option><option value="46">Egypt</option><option value="47">El Salvador</option><option value="48">Equatorial Guinea</option><option value="49">Eritrea</option><option value="50">Estonia</option><option value="51">Ethiopia</option><option value="189">Falkland Islands</option><option value="191">Faroe Islands</option><option value="52">Fiji</option><option value="53">Finland</option><option value="54">France</option><option value="193">French Guiana</option><option value="277">French Polynesia</option><option value="56">Gabon</option><option value="57">Gambia</option><option value="58">Georgia</option><option value="59">Germany</option><option value="60">Ghana</option><option value="194">Gibraltar</option><option value="61">Greece</option><option value="195">Greenland</option><option value="192">Grenada</option><option value="196">Guadeloupe</option><option value="62">Guam</option><option value="198">Guatemala</option><option value="270">Guernsey</option><option value="63">Guinea</option><option value="65">Guyana</option><option value="200">Haiti</option><option value="66">Honduras</option><option value="67">Hong Kong</option><option value="68">Hungary</option><option value="69">Iceland</option><option value="70">India</option><option value="71">Indonesia</option><option value="278">Iran</option><option value="279">Iraq</option><option value="74">Ireland</option><option value="323">Isle of Man</option><option value="75">Israel</option><option value="76">Italy</option><option value="202">Jamaica</option><option value="78">Japan</option><option value="288">Jersey (Channel Islands)</option><option value="79">Jordan</option><option value="80">Kazakhstan</option><option value="81">Kenya</option><option value="203">Kiribati</option><option value="82">Kuwait</option><option value="83">Kyrgyzstan</option><option value="84">Lao People's Democratic Republic</option><option value="85">Latvia</option><option value="86">Lebanon</option><option value="87">Lesotho</option><option value="88">Liberia</option><option value="281">Libya</option><option value="90">Liechtenstein</option><option value="91">Lithuania</option><option value="92">Luxembourg</option><option value="208">Macau</option><option value="93">Macedonia</option><option value="94">Madagascar</option><option value="95">Malawi</option><option value="96">Malaysia</option><option value="97">Maldives</option><option value="98">Mali</option><option value="99">Malta</option><option value="207">Marshall Islands</option><option value="210">Martinique</option><option value="100">Mauritania</option><option value="212">Mauritius</option><option value="241">Mayotte</option><option value="101">Mexico</option><option value="102">Moldova, Republic of</option><option value="103">Monaco</option><option value="104">Mongolia</option><option value="290">Montenegro</option><option value="294">Montserrat</option><option value="105">Morocco</option><option value="106">Mozambique</option><option value="242">Myanmar</option><option value="107">Namibia</option><option value="108">Nepal</option><option value="109">Netherlands</option><option value="110">Netherlands Antilles</option><option value="213">New Caledonia</option><option value="111" selected>New Zealand</option><option value="112">Nicaragua</option><option value="113">Niger</option><option value="114">Nigeria</option><option value="217">Niue</option><option value="214">Norfolk Island</option><option value="272">North Korea</option><option value="116">Norway</option><option value="117">Oman</option><option value="118">Pakistan</option><option value="222">Palau</option><option value="282">Palestine</option><option value="119">Panama</option><option value="219">Papua New Guinea</option><option value="120">Paraguay</option><option value="121">Peru</option><option value="122">Philippines</option><option value="221">Pitcairn</option><option value="123">Poland</option><option value="124">Portugal</option><option value="126">Qatar</option><option value="315">Republic of Kosovo</option><option value="127">Reunion</option><option value="128">Romania</option><option value="129">Russia</option><option value="130">Rwanda</option><option value="205">Saint Kitts and Nevis</option><option value="206">Saint Lucia</option><option value="324">Saint Martin</option><option value="237">Saint Vincent and the Grenadines</option><option value="132">Samoa (Independent)</option><option value="227">San Marino</option><option value="255">Sao Tome and Principe</option><option value="133">Saudi Arabia</option><option value="134">Senegal</option><option value="326">Serbia</option><option value="135">Seychelles</option><option value="136">Sierra Leone</option><option value="137">Singapore</option><option value="302">Sint Maarten</option><option value="138">Slovakia</option><option value="139">Slovenia</option><option value="223">Solomon Islands</option><option value="140">Somalia</option><option value="141">South Africa</option><option value="257">South Georgia and the South Sandwich Islands</option><option value="142">South Korea</option><option value="311">South Sudan</option><option value="143">Spain</option><option value="144">Sri Lanka</option><option value="293">Sudan</option><option value="146">Suriname</option><option value="225">Svalbard and Jan Mayen Islands</option><option value="147">Swaziland</option><option value="148">Sweden</option><option value="149">Switzerland</option><option value="285">Syria</option><option value="152">Taiwan</option><option value="260">Tajikistan</option><option value="153">Tanzania</option><option value="154">Thailand</option><option value="233">Timor-Leste</option><option value="155">Togo</option><option value="232">Tonga</option><option value="234">Trinidad and Tobago</option><option value="156">Tunisia</option><option value="157">Turkey</option><option value="158">Turkmenistan</option><option value="287">Turks & Caicos Islands</option><option value="159">Uganda</option><option value="161">Ukraine</option><option value="162">United Arab Emirates</option><option value="262">United Kingdom</option><option value="163">Uruguay</option><option value="165">Uzbekistan</option><option value="239">Vanuatu</option><option value="166">Vatican City State (Holy See)</option><option value="167">Venezuela</option><option value="168">Vietnam</option><option value="169">Virgin Islands (British)</option><option value="238">Virgin Islands (U.S.)</option><option value="188">Western Sahara</option><option value="170">Yemen</option><option value="173">Zambia</option><option value="174">Zimbabwe</option></select><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div class="mc-field-group"><!-- [et_pb_line_break_holder] --> <label for="mce-MMERGE5">Business Name <span class="asterisk">*</span><!-- [et_pb_line_break_holder] --></label><!-- [et_pb_line_break_holder] --> <input type="text" value="" name="MMERGE5" class="required" id="mce-MMERGE5"><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div class="mc-field-group"><!-- [et_pb_line_break_holder] --> <label for="mce-MMERGE7">Industry Type <span class="asterisk">*</span><!-- [et_pb_line_break_holder] --></label><!-- [et_pb_line_break_holder] --> <select name="MMERGE7" class="required" id="mce-MMERGE7"><!-- [et_pb_line_break_holder] --> <option value=""></option><!-- [et_pb_line_break_holder] --> <option value="Accounting">Accounting</option><!-- [et_pb_line_break_holder] --><option value="Legal">Legal</option><!-- [et_pb_line_break_holder] --><option value="Real Estate">Real Estate</option><!-- [et_pb_line_break_holder] --><option value="Bookkeeper/Admin">Bookkeeper/Admin</option><!-- [et_pb_line_break_holder] --><option value="Marketing">Marketing</option><!-- [et_pb_line_break_holder] --><option value="Health">Health</option><!-- [et_pb_line_break_holder] --><option value="Financial Services">Financial Services</option><!-- [et_pb_line_break_holder] --><option value="Beauty">Beauty</option><!-- [et_pb_line_break_holder] --><option value="Counselling">Counselling</option><!-- [et_pb_line_break_holder] --><option value="Mentoring">Mentoring</option><!-- [et_pb_line_break_holder] --><option value="Business Consultancy Services">Business Consultancy Services</option><!-- 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value="Director">Director</option><!-- [et_pb_line_break_holder] --><option value="Manager">Manager</option><!-- [et_pb_line_break_holder] --><option value="Sales">Sales</option><!-- [et_pb_line_break_holder] --><option value="Other">Other</option><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> </select><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div class="mc-field-group input-group"><!-- [et_pb_line_break_holder] --> <strong>I have read and agree to the rules of engagement <span class="asterisk">*</span><!-- [et_pb_line_break_holder] --></strong><!-- [et_pb_line_break_holder] --> <ul><li><input type="radio" value="Yes" name="MMERGE18" id="mce-MMERGE18-0"><label for="mce-MMERGE18-0">Yes</label></li><!-- [et_pb_line_break_holder] --></ul><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div class="mc-field-group input-group"><!-- [et_pb_line_break_holder] --> <strong>How did you hear about us? </strong><!-- 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type="checkbox" value="32" name="group[22253][32]" id="mce-group[22253]-22253-5"><label for="mce-group[22253]-22253-5">Other</label></li><!-- [et_pb_line_break_holder] --></ul><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div class="mc-field-group input-group"><!-- [et_pb_line_break_holder] --> <strong>Membership Options </strong><!-- [et_pb_line_break_holder] --> <ul><li><input type="checkbox" value="64" name="group[22261][64]" id="mce-group[22261]-22261-0"><label for="mce-group[22261]-22261-0">Std 6 Month ($29 per mth)</label></li><!-- [et_pb_line_break_holder] --><li><input type="checkbox" value="128" name="group[22261][128]" id="mce-group[22261]-22261-1"><label for="mce-group[22261]-22261-1">Std 6 Month Up Front ($159)</label></li><!-- [et_pb_line_break_holder] --><li><input type="checkbox" value="256" name="group[22261][256]" id="mce-group[22261]-22261-2"><label for="mce-group[22261]-22261-2">Std 6 Month Corporate/Couple* ($49 per 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style="display:none"></div><!-- [et_pb_line_break_holder] --> </div> <!-- real people should not fill this in and expect good things - do not remove this or risk form bot signups--><!-- [et_pb_line_break_holder] --> <div style="position: absolute; left: -5000px;" aria-hidden="true"><input type="text" name="b_2c48fc9d6bd8b12257b39e407_b4554be978" tabindex="-1" value=""></div><!-- [et_pb_line_break_holder] --> <div class="clear"><input type="submit" value="Subscribe" name="subscribe" id="mc-embedded-subscribe" class="button"></div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --></form><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><script type='text/javascript' src='//s3.amazonaws.com/downloads.mailchimp.com/js/mc-validate.js'></script><script type='text/javascript'>(function($) {window.fnames = new Array(); window.ftypes = new 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