TEST PAGE ACG Chicago Membership Form Date of Submission* MM DD YYYY Name* 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 Advisor A member who generates income from providing services to corporate and/or equity group members. Service members include: attorneys; accountants; strategy consultants; valuators; recruiters etc.Corporate In-House CounselCorporate Development- not sales (VP - not sales in acorporation. (VP corporatedevelopment, VP Strategic Acquisition not sales rolesCorporate Finance - not Inv. bankers, advisors or lenders(CFO, Comptoller, etc.)Corporate Management - (Member influences the development ofcorporate growth of an operating company,i.e. chairman, chief executive officer, chief operating officer, principal orVP strategic planning. Not meant tobe senior execs from firms inother categories)Corporate Management – Entrepreneur (A leader who identifiesa need, organizes and manages any enterprise usually withconsiderable initiative and innovation. This includes sourcing and organizingthe required resources, and taking onthe associated risks and rewards.)Capital Providers-Equity GroupNot funding FundAdvisor– Accountant (Member is an accountantwhose services include providing tax, audit, and/or accounting advice to corporate and/or equitygroup members.)Advisor – Attorney (Member is anattorney whose services includeadvising corporate and/or equitygroup members.)Advisor – Consultant (Member is aconsultant whose services includeproviding strategic planning advice tocorporate and/or service members.)Advisor – Recruiter(Member is an executive or otherpersonnel recruiter for eitherfull-time or part-timeemployees.)Capital Providers – Equity GroupManaging FundCapital Providers – Equity GroupNot Managing Fund(Independent Sponsor)Capital Providers – Family OfficesCapital Providers – Hedge FundCapital Providers – Venture CapitalCommunity – Other – Educators(Member is employed by a college or university)Community – Other – Government (Member isemployed by thegovernment)Community – Other – NGO Executive/Leaders(Member is employed by a Not-for-profit Organization)Intermediaries – Investment BankersIntermediaries – Business BrokersIntermediaries – UnderwritersNature 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 FeeYou 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). Price: $400.00 Authorized Signature:*3. ACG Chicago will formally review your application for acceptance. For additional information, contact ACG Chicago, 877-ACG-NETWORK (877-224-6389).Privacy* By using this form you agree with the storage and handling of your data by this website.