INTELLENET LTD

P.O. Box 350

Gladwyne, PA 19035

PROPOSAL FOR MEMBERSHIP FORM

ONLY ACTIVE INTELLENET MEMBERS MAY USE THIS FORM.
Other inquiries should be emailed to intellenet@intellenetwork.org.

Approved 07/08/04

Recommending Member: _________________________ Date:__________________
Recommending Member Email Address: ____________________________________
Telephone: ___________________________ Fax:____________________________

Person Recommended:

Name: _______________________________ Title: _________________________

Company_____________________________ Location: _________________________

Telephone____________________________ Fax: _____________________________

Email Address: ___________________________________________________________

Mailing Address: _________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

How Known (Personal, Business, Both, Other)?_________________________________

How Long Known? ______________

Does Recommended Party meet all INTELLENET Requirements (See By-Laws and
Code of Ethics)? __________________________________________________________

Please provide a brief narrative explaining the following: Has the Candidate expressed a desire to be a member of INTELLENET? If the proposed member is located in an area where we have coverage, why would that member be an asset to INTELLENET? Are there any other factors you would like to mention? (i.e. Expertise, Specialties, Special Connections or knowledge).

Submit the completed form to the Executive Director, James P Carino by: E-mail to intellenet@intellenetwork.org; FAX to 1.800.784.2020 or; MAIL to INTELLENET Ltd, PO Box 350, Gladwyne, PA 19035

Thank you.