Who's Who Global NetWork(SM)

membership application

Who's Who Global NetWork(SM) is pleased to offer value-added telecommunications as part of our membership offering, which is by invitation only. If you have been invited to join, or know that you qualify for membership based on the admissions criteria you may complete your application in one of three (3) ways:

By fax:

print out this page, complete as requested, & fax to: +1-212-877-1905

By postal service mail:

print out this page, complete as requested & mail to:
Who's Who Global NetWork, Box 1000, New York, NY 10024 USA

By e-mail:

print out this page, complete as requested, scan and save as an Adobe ® PDF document, and email to:
webmaster@whoswho-online.com

Names:

First - ______________ Middle - ____________ Last (Family) - _____________________

Mailing Address: ______________________________________________________________

City: ________________________________ State/Province: ____________________

Postal Code: ________________________ Country: ____________________

Current Company/Employer: __________________________________________________

Current Position/Job Title: __________________________________________________

Telephone: Country Code - _____ Area/City Code - ______ Number(s) ____________________

Fax: Country Code - _____ Area/City Code - ______ Number(s) ____________________

Current E-mail Address(es): 1) _______________________________ 2) __________________

TO WHICH E-MAIL ADDRESS WOULD YOU LIKE YOUR MAIL FORWARDED? ________________________________________

On what basis is your application based? Complete one or more below:
a) Listed in a reputable Who's Who (or equivalent) registry (Which one? What year?):
______________________________________________________________________
b) Earned a doctoral degree (Which school? What degree and year?)
______________________________________________________________________
c) Elected public officials (What office? Term runs/ran until when?)
_______________________________________________________________________
d) Senior corporate officer (What rank and company? Since when?)
_______________________________________________________________________

Part I (your name/numeric alias - that which is to the left of the @ symbol)

Please select the level of membership you desire and enter the requested information in the space below your selection:

___ Anonymous Membership (US$48.00/year)

your personal, permanent e-mail address will be a randomly-generated number
e.g., 90368538821@
Your numeric alais will be randomly-generated; please proceed to Part II

___ Basic Membership (US$54.00/year)

use of first.middle.last, first.mi.last or first.last format for permanent e-mail address
e.g., john.biddle.smith@ or john.b.smith@ or john.smith@
__________________ . _______________ . _________________________ @

___ Professional Membership (US$60.00/year)

use of fi.mi.last or fi.last format for permanent e-mail address
e.g., j.b.smith@ or j.smith@ or jbsmith@ or jsmith@
___ . ___ . ____________________________ @

Part II (your e-mail domain - that which is to the right of the @ symbol)

Please select the domain appropriate to your application using a check mark on the left:

• ___ whoswho-americas.com
• ___ whoswho-europe.com
• ___ whoswho-asia.com
• ___ whoswho-world.com

Who's Who Global NetWork(SM) is pleased to accept the American Express Card. To pay by American Express, please complete the information below:

Cardholder Name: ______________________________________

American Express Account Number: _________-_________-_________-________

Expiration Date: ____ ____ (mm.yyyy)

Who's Who Global Network(SM) is authorized to charge US$___________ to my account.

Signature: ( X )______________________________

You may remit your payment, or we will bill you later.

Applications submitted by U.S. mail may be accompanied by a check, money order or bank draft drawn in U.S. funds on a U.S. bank. Applicants may also request billing only after they have been advised of the availability of their first choice selection and/or until their applications have been screened and pre-approved. Balances may always be settled by electronic funds transfer or the American Express Card.

Webmaster