FBLN Application — Pacific Family Business Institute

Membership Application: PFBI Family Business Leadership Network

Attention: Before completing this application, please read about the PFBI Family Business Leadership Network and the commitments associated with membership.

The information provided in this application form will be held confidential and used for contact and evaluation purposes only. We will follow up to schedule a face-to-face or telephone interview if necessary.

Your Name *

Your Name

First Name

Last Name

Business Name *

Industry *

Please describe the core business. *

Number of Employees *

Family Members in the Business *

Please list the names, ages, and relationships of all family members, including spouses, who work in the business with you.

Your Role(s) in the Business *

List all positions you have held in the family business, including approximate dates, beginning with your current position and title.

Which generation do you represent? *

Are you a sharedholder in the family business? *

Yes

What are your professional goals and vision for the future regarding the family business? *

What would you like to learn by participating in the PFBI Family Business Leadership Network? *

What can you contribute to the PFBI Family Business Leadership Network? *

Date of Birth

YYYY

Mailing Address *

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Business Phone *

Business Phone

(###)

###

####

Cell Phone *

Cell Phone

(###)

###

####

Email Address *

Do you have any comments or concerns?

Agreement *

I have read the description of the PFBI Family Business Leadership Network and wish to apply for membership. If accepted, I agree to attend the meetings, actively participate in group discussions, and pay the membership fee as described in that document.