TEST PAGE ACG Chicago Membership Form Date of Submission*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name* Mr.Mrs.MissMs.Dr.Prof.Rev. (Mr., Ms., etc.) First M.I. Last Informal/Nickname (for badges)*Date of Birth MM DD YYYY Title*Company*Address*Floor/Suite#City*State*Zip Code*Work Phone Number*Email Address* Cell Phone Number*Type of Business*Web Site AddressTwitter Account NameOther Social Networking ParticipationAdd LinkedInOther social AccountsNetworking AccountsHow did you hear about ACG? Check all that apply. ACG News Annual Conference Announcement Event Announcement Event Attendance Magazine Online – Social Network eNewsletter Other organization Newspaper Member Other referral Other Online – Social Network (please identify)eNewsletter Other organization (please identify)Other referral (please identify)Other (please identify)Please check which segments interest you* Private Equity Women’s Network NextGen Leaders (Under 40 Professionals) International Growth Food Industry Healthcare Industry Entrepreneurship all Manufacturing Industry Indicate your Primary Occupational Role Listed below are the primary membership categories. They are: Corporate, Capital Providers, Intermediaries, Advisors, Community, or Other. Within each of the six categories of membership are sub-classifications. Please indicate the one classification which most closely matches your profession.Corporate*A member who works for a company (public or private) and whose job description includes growing the company organically, through acquisitions, divestitures, joint ventures, alliances, strategic planning, product Corporate In-House CounselCorporate Development - not sales in a corporation. (VP corporateCorporate Finance - not Inv. bankers, advisors or lenders (CFO, Comptoller, etc.)Corporate Management (Member influences the development of corporate growth of an operating company, i.e. chairman, chief executive officer, chief operating officer, principal or owner, VP strategic planning. Not meant to be senior execs from firms in other categories)Corporate Management – Entrepreneur (A leader who identifies a need, organizes and manages any enterprise usually with considerable initiative and innovation. This includes sourcing and organizing the required resources, and taking on the associated risks and rewards.)AdvisorA member who generates income from providing services to corporate and/or equity group members. Service members include: attorneys; accountants; strategy consultants; valuators; recruiters etc.Advisor- Accountant (Member is an accountant whose services include providing tax, audit, and/or accounting advice to corporate and/or equity group members.)Advisor – Attorney (Member is an attorney whose services include advising corporate and/or equity group members.)Advisor – Banking (Member provides interest rate management or cash management.)Advisor – Consultant (Member is a consultant whose services include providing strategic planning advice to corporate and/or service members.)Advisor – Recruiter (Member is an executive or other personnel recruiter for either full-time or part-time employees.)Advisor – Technology (Member is a technology provider whose services include hardware, software, internet, or databases, etc. This includes M&A data services)Advisor – Valuator (Member is a business valuator and/or compiles statistics for use in valuations.)Advisor – Wealth Manager (Members employed by a wealth management firm)Advisor – Other Services (Member provides other services to corporate and/or equity groups but does not fit into any of the above categories such as transaction insurance or salelease back and other real estate services)Capital Providers- your primary focus even if work in multiple areas*Equity Group Managing FundEquity Group Not Managing Fund (Independent Sponsor)Family OfficesHedge FundVenture CapitalLender – Senior DebtLender - Junior DebtLender – MezzanineLender – OtherLimited PartnerCommunity*Other – Educators (Member is employed by a college or university)Other – Government (Member is employed by the government)Other – NGO Executive/Leaders (Member is employed by a Not-for-profit Organization)Intermediaries*Member is an intermediary whose services include bringing buyers and sellers together and/or identifying sources of debt and equity financing Investment BankersBusiness BrokersUnderwritersOtherOther Professional Not Listed AboveNature of Business and Job Responsibilities in 30 words or less*Number of Years with Firm*(if less than 3 years, indicate previous position below)Previous Company:Title:Address, #/Fl.City, State ZipProfessional Society Memberships:Educational Background (list school, degree, year of graduation)SchoolDegreeGraduation Why do you wish to be a member of the ACG Chicago Chapter?Membership Requirements 1. A letter of recommendation from a current ACG Chicago member should be forwarded via e-mail to Membership@ACGChicago.com or mailed to: ACG Chicago Membership, 200 West Monroe Street, #1401, Chicago, IL 60606 Please proactively ask your sponsor to send this email with a brief description of how they know you and why they feel you would be an asset to the ACG Chicago Network.Sponsor’s Name*Sponsor’s Company Name*2. Payment of $400.00 for applications by credit card or check to be submitted with application. Processing will occur upon approval.Membership Fee Price: $400.00 You may pay with Credit Card via Paypal when you hit the submit button. If you wish to pay by check, please submit with this application (you can download a PDF upon submission) and made payable to: ACG Chicago200 West Monroe Street, #1401 Chicago, IL 60606 ACG Chicago will formally review your application for acceptance. For additional information, contact ACG Chicago, 877-ACG-NETWORK (877-224-6389). Authorized Signature:3. ACG Chicago will formally review your application for acceptance. For additional information, contact ACG Chicago, 877-ACG-NETWORK (877-224-6389).