EWIIN Membership Form – Ebony Women International Insurance Network

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EWIIN Membership Application

Please complete. Membership is subject to a nominal annual fee. Donations and contributions are accepted.

(EWIIN is a registered not-for-profit #1236758-1)

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Email *

Phone

Are you currently employed in the P&C Insurance Industry?

Yes
No

Employer

Employer Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Current Role

Years in Current Role

Education

How did you hear about EWIIN?

Referred By

What are you interested in getting from EWIIN?

Mentorship
Networking
Sponsorship
Other

Select Membership Type (Annual)

Student
Individual
Associate
Corporate

Consent

Yes, I agree to receive emails from EWIIN for future Events

Refer to our Privacy Policy.

Total

$0.00

Stripe Credit Card *

Card

Name on Card